Diversified Health Occupations (Red Textbook) 7th Editions

DIVERSIFIED
HEALTH
OCCUPATIONS
Seventh Edition
Louise Simmers, MEd, RN

Karen Simmers-Nartker, BSN, RN
Sharon Simmers-Kobelak, BBA
Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States
Diversified Health Occupations, Seventh © 2009 Delmar, Cengage Learning
Edition
ALL RIGHTS RESERVED. No part of this work covered by the copyright herein may be
Louise Simmers
reproduced, transmitted, stored, or used in any form or by any means, graphic, electronic, or
Karen Simmers-Nartker
mechanical, including but not limited to photocopying, recording, scanning, digitizing, taping,
Sharon Simmers-Kobelak
Web distribution, information networks, or information storage and retrieval systems, except as
Vice President, Career and Professional permitted under Section 107 or 108 of the 1976 United States Copyright Act, without the prior
written permission of the publisher.
Editorial: Dave Garza
Director of Learning Solutions:
Matthew Kane For product information and technology assistance, contact us at
Cengage Learning Academic Resource Center, 1-800-423-0563
Managing Editor: Marah Bellegarde
For permission to use material from this text or product, submit all requests
Acquisitions Editor: Matthew Seeley
online at www.cengage.com/permissions
Senior Product Manager: Juliet Steiner Further permissions questions can be emailed to
Editorial Assistant: Megan Tarquinio permissionrequest@cengage.com
Vice President, Marketing, Career and

Professional: Jennifer McAvey ExamView® and ExamView Pro® are registered trademarks of FSCreations, Inc. Windows is a
Marketing Manager: Michele McTighe registered trademark of the Microsoft Corporation used herein under license. Macintosh and
Power Macintosh are registered trademarks of Apple Computer, Inc. Used herein under license.
Technology Project Manager: Ben Knapp
Production Director: Carolyn Miller © 2009 Cengage Learning. All Rights Reserved. Cengage Learning WebTutor™ is a trademark of
Cengage Learning.
Senior Art Director: Jack Pendleton
Content Project Manager: Anne Sherman Library of Congress Control Number: 2007941692
ISBN-13: 978-1-4180-3021-6
ISBN-10: 1-4180-3021-X
Delmar Cengage Learning

5 Maxwell Drive
Clifton Park, NY 12065-2919
USA
Cengage Learning products are represented in Canada by Nelson Education, Ltd.
For your lifelong learning solutions, visit delmar.cengage.com
Visit our corporate website at www.cengage.com
Notice to the Reader

Publisher does not warrant or guarantee any of the products described herein or perform any
independent analysis in connection with any of the product information contained herein.
Publisher does not assume, and expressly disclaims, any obligation to obtain and include
information other than that provided to it by the manufacturer. The reader is expressly warned
to consider and adopt all safety precautions that might be indicated by the activities described
herein and to avoid all potential hazards. By following the instructions contained herein, the
reader willingly assumes all risks in connection with such instructions. The publisher makes no
representations or warranties of any kind, including but not limited to, the warranties of fitness
for particular purpose or merchantability, nor are any such representations implied with respect
to the material set forth herein, and the publisher takes no responsibility with respect to such
material. The publisher shall not be liable for any special, consequential, or exemplary damages
resulting, in whole or part, from the readers’ use of, or reliance upon, this material.
Printed in Canada
1 2 3 4 5 6 7 12 11 10 09 08
CONTENTS
Preface xi
How to Use xvii
Acknowledgments xxv
PART 1
Basic Health Care Concepts and Skills 1
CHAPTER 1 History and Trends of Health Care 2
Objectives 2 Today’s Research: Tomorrow’s Health Care 24
Key Terms 3 Summary 25
1:1 History of Health Care 3 Internet Searches 25
1:2 Trends in Health Care 14 Review Questions 25
CHAPTER 2 Health Care Systems 26

Objectives 26 2:5 Organizational Structure 35
Key Terms 27 Today’s Research: Tomorrow’s Health Care 36
2:1 Private Health Care Facilities 27 Summary 37
2:2 Government Agencies 31 Internet Searches 37
2:3 Voluntary or Nonprofit Agencies 32 Review Questions 37
2:4 Health Insurance Plans 32
CHAPTER 3 Careers in Health Care 38

Objectives 38 3:2F Nursing Careers 55
Key Terms 39 3:2G Nutrition and Dietary Services
3:1 Introduction to Health Careers 40 Careers 57
3:2 Therapeutic Services Careers 46 3:2H Veterinary Careers 58
3:2A Dental Careers 46 3:2I Vision Services Careers 60
3:2B Emergency Medical Services 3:2J Other Therapeutic Services Careers 61
Careers 48 3:3 Diagnostic Services Careers 67
3:2C Medical Careers 50 3:4 Health Informatics Careers 72
3:2D Mental and Social Services Careers 52 3:5 Support Services Careers 76
3:2E Mortuary Careers 54
iv CONTENTS
3:6 Biotechnology Research Summary 80

and Development Careers 77 Internet Searches 80
Today’s Research: Tomorrow’s Health Care 79 Review Questions 80
CHAPTER 4 Personal and Professional Qualities

of a Health Care Worker 81
Objectives 81 4:6 Stress 95
Key Terms 82 4:7 Time Management 97
4:1 Personal Appearance 82 Today’s Research: Tomorrow’s Health Care 100
4:2 Personal Characteristics 85 Summary 100
4:3 Effective Communications 86 Internet Searches 101
4:4 Teamwork 92 Review Questions 101
4:5 Professional Leadership 94
CHAPTER 5 Legal and Ethical Responsibilities 103

Objectives 103 5:5 Professional Standards 115
5:1 Legal Responsibilities 104 Summary 117
5:2 Ethics 111 Internet Searches 118
5:3 Patients’ Rights 112 Review Questions 118
5:4 Advance Directives for Health Care 113
CHAPTER 6 Medical Terminology 119

6:1 Using Medical Abbreviations 120 Internet Searches 139
6:2 Interpreting Word Parts 127 Review Questions 139
CHAPTER 7 Anatomy and Physiology 140

Objectives 140 7:9 Lymphatic System 194
Key Terms 141 7:10 Respiratory System 197
7:1 Basic Structure of the Human Body 141 7:11 Digestive System 203
7:2 Body Planes, Directions, and Cavities 148 7:12 Urinary System 210
7:3 Integumentary System 151 7:13 Endocrine System 216
7:4 Skeletal System 156 7:14 Reproductive System 223
7:5 Muscular System 163 Today’s Research: Tomorrow’s Health Care 232
7:6 Nervous System 168 Summary 233
7:7 Special Senses 176 Internet Searches 233
7:8 Circulatory System 183 Review Questions 233
CHAPTER 8 Human Growth and Development 235

8:1 Life Stages 236 Internet Searches 256
8:2 Death and Dying 247 Review Questions 256
8:3 Human Needs 250
Contents v
CHAPTER 9 Cultural Diversity 257

Objectives 257 9:4 Respecting Cultural Diversity 272
9:1 Culture, Ethnicity, and Race 258 Today’s Research: Tomorrow’s Health Care 273
9:2 Bias, Prejudice, and Stereotyping 260 Internet Searches 273
9:3 Understanding Cultural Diversity 261 Review Questions 274
CHAPTER 10 Geriatric Care 275

Objectives 275 10:5 Meeting the Needs of the Elderly 291
10:1 Myths on Aging 276 Today’s Research: Tomorrow’s Health Care 293
10:2 Physical Changes of Aging 278 Internet Searches 293
10:3 Psychosocial Changes of Aging 284 Review Questions 294
10:4 Confusion and Disorientation
in the Elderly 287
CHAPTER 11 Nutrition and Diets 295

Objectives 295 11:5 Weight Management 305
Key Terms 296 11:6 Therapeutic Diets 309
11:1 Fundamentals of Nutrition 296 Today’s Research: Tomorrow’s Health Care 312
11:2 Essential Nutrients 297 Summary 312
11:3 Utilization of Nutrients 301 Internet Searches 313
11:4 Maintenance of Good Nutrition 302 Review Questions 13
CHAPTER 12 Computer Technology in Health Care 314

Objectives 314 12:5 Computer Protection and Security 329
12:1 Introduction 315 Summary 331
12:2 What Is a Computer System? 316 Internet Searches 331
12:3 Computer Applications 319 Review Questions 331
12:4 Using the Internet 326
CHAPTER 13 Promotion of Safety 333

13:1 Using Body Mechanics 334 Internet Searches 348
13:2 Preventing Accidents and Injuries 336 Review Questions 349
13:3 Observing Fire Safety 343
vi CONTENTS
CHAPTER 14 Infection Control 350

Objectives 350 C: Donning and Removing Sterile
Key Terms 351 Gloves 392
14:1 Understanding the Principles D: Changing a Sterile Dressing 395
of Infection Control 351 14:9 Maintaining Transmission-Based
14:2 Bioterrorism 357 Isolation Precautions 397
14:3 Washing Hands 359 A: Donning and Removing
14:4 Observing Standard Precautions 363 Transmission-Based Isolation
14:5 Sterilizing with an Autoclave 371 Garments 402
A: Wrapping Items for Autoclaving 373 B: Working in a Hospital
B: Loading and Operating Transmission-Based Isolation Unit 406
an Autoclave 377 Summary 409
14:6 Using Chemicals for Disinfection 379 Today’s Research: Tomorrow’s Health Care 410
14:7 Cleaning with an Ultrasonic Unit 381 Internet Searches 411
14:8 Using Sterile Techniques 385 Review Questions 411
A: Opening Sterile Packages 386
B: Preparing a Sterile Dressing Tray 389
CHAPTER 15 Vital Signs 412

Objectives 412 G: Measuring and Recording Temporal
Key Terms 413 Temperature 430
15:1 Measuring and Recording Vital Signs 413 15:3 Measuring and Recording Pulse 431
15:2 Measuring and Recording Temperature 414 15:4 Measuring and Recording Respirations 433
A: Cleaning a Clinical Thermometer 419 15:5 Graphing TPR 435
B: Measuring and Recording Oral 15:6 Measuring and Recording Apical Pulse 438
Temperature 421 15:7 Measuring and Recording Blood
C: Measuring and Recording Rectal Pressure 440
Temperature 423 Today’s Research: Tomorrow’s Health Care 446
D: Measuring and Recording Axillary Summary 446
Temperature 424 Internet Searches 446
E: Measuring and Recording Tympanic Review Questions 447
(Aural) Temperature 426
F: Measuring Temperature with an
Electronic Thermometer 428
CHAPTER 16 First Aid 448

Objectives 448 F: Performing CPR—Obstructed
Key Terms 449 Airway on Conscious Infant 471
16:1 Providing First Aid 449 16:3 Providing First Aid for Bleeding and
16:2 Performing Cardiopulmonary Wounds 473
Resuscitation 452 16:4 Providing First Aid for Shock 479
A: Performing CPR—One-Person 16:5 Providing First Aid for Poisoning 483
Adult Rescue 458 16:6 Providing First Aid for Burns 488
B: Performing CPR—Two-Person 16:7 Providing First Aid for Heat Exposure 493
Adult Rescue 462 16:8 Providing First Aid for Cold Exposure 496
C: Performing CPR on Infants 464 16:9 Providing First Aid for Bone and Joint
D: Performing CPR on Children 467 Injuries 498
E: Performing CPR—Obstructed 16:10 Providing First Aid for Specific Injuries 505
Airway on Conscious Adult or Child 469 16:11 Providing First Aid for Sudden Illness 513
Contents vii
16:12 Applying Dressings and Bandages 519 Internet Searches 526

Summary 525 Review Questions 526
Today’s Research: Tomorrow’s Health Care 526
CHAPTER 17 Preparing for the World of Work 528

Objectives 528 17:5 Determining Net Income 543
Key Terms 529 17:6 Calculating a Budget 545
17:1 Developing Job-Keeping Skills 529 Summary 547
17:2 Writing a Cover Letter and Preparing Today’s Research: Tomorrow’s Health Care 548
a Résumé 530 Internet Searches 548
17:3 Completing Job Application Forms 537 Review Questions 549
17:4 Participating in a Job Interview 539
PART 2
Special Health Care Skills 550
CHAPTER 18 Dental Assistant Skills 552
Objectives 552 A: Preparing Alginate 602
Key Terms 553 B: Preparing Rubber Base (Polysulfide) 605
Career Highlights 554 C: Pouring a Plaster Model 608
18:1 Identifying the Structures and Tissues D: Pouring a Stone Model 612
of a Tooth 554 E: Trimming a Model 613
18:2 Identifying the Teeth 558 18:11 Making Custom Trays 615
18:3 Identifying Teeth Using the Universal/ 18:12 Maintaining and Loading an
National Numbering System and the Anesthetic Aspirating Syringe 618
Federation Dentaire International (FDI) A: Maintaining an Anesthetic
System 560 Aspirating Syringe 621
A: Identifying Teeth Using the B: Loading an Anesthetic Aspirating
Universal/National Numbering Syringe 622
System 563 18:13 Mixing Dental Cements and Bases 624
B: Identifying Teeth Using the A: Preparing Varnish 626
Federation Dentaire International B: Preparing Calcium Hydroxide 627
(FDI) Numbering System 564 C: Preparing Polycarboxylate 629
18:4 Identifying the Surfaces of the D: Preparing Zinc Oxide Eugenol (ZOE) 630
Teeth 565 18:14 Preparing Restorative Materials—
18:5 Charting Conditions of the Teeth 568 Amalgam and Composite 632
18:6 Operating and Maintaining Dental A: Preparing Amalgam 635
Equipment 574 B: Preparing Composite 637
18:7 Identifying Dental Instruments and 18:15 Developing and Mounting Dental
Preparing Dental Trays 584 Radiographs (X-Rays) 639
18:8 Positioning a Patient in the Dental A: Developing Dental Radiographs
Chair 592 (X-Rays) 642
18:9 Demonstrating Brushing and Flossing B: Mounting Dental Radiographs
Techniques 594 (X-Rays) 644
A: Demonstrating Brushing Technique 595 Today’s Research: Tomorrow’s Health Care 646
B: Demonstrating Flossing Technique 597 Summary 646
18:10 Taking Impressions and Pouring Internet Searches 647
Models 598 Review Questions 647
viii CONTENTS
CHAPTER 19 Laboratory Assistant Skills 648

Objectives 648 19:6 Preparing and Staining a Blood Film
Key Terms 649 or Smear 682
Career Highlights 649 A: Preparing a Blood Film or Smear 684
19:1 Operating the Microscope 650 B: Staining a Blood Film or Smear 685
19:2 Obtaining and Handling Cultures 656 19:7 Testing for Blood Types 687
A: Obtaining a Culture Specimen 658 19:8 Performing an Erythrocyte
B: Preparing a Direct Smear 660 Sedimentation Rate 691
C: Streaking an Agar Plate 662 19:9 Measuring Blood-Sugar (Glucose)
D: Transferring Culture from Agar Level 695
Plate to Slide 664 19:10 Testing Urine 699
E: Staining with Gram’s Stain 666 19:11 Using Reagent Strips to Test Urine 701
19:3 Puncturing the Skin to Obtain 19:12 Measuring Specific Gravity 705
Capillary Blood 668 19:13 Preparing Urine for Microscopic
19:4 Performing a Microhematocrit 671 Examination 709
19:5 Measuring Hemoglobin 676 Today’s Research: Tomorrow’s Health Care 713
A: Measuring Hemoglobin with a Summary 713
Hemoglobinometer 677 Internet Searches 714
B: Measuring Hemoglobin with a Review Questions 714
Photometer 680
CHAPTER 20 Medical Assistant Skills 715

Objectives 715 20:5 Assisting with Minor Surgery
Key Terms 716 and Suture Removal 748
Career Highlights 716 A: Assisting with Minor Surgery 751
20:1 Measuring/Recording Height B: Assisting with Suture Removal 755
and Weight 717 20:6 Recording and Mounting an
A: Measuring/Recording Height Electrocardiogram 756
and Weight 721 20:7 Using the Physicians’ Desk Reference
B: Measuring/Recording Height (PDR) 768
and Weight of an Infant 723 20:8 Working with Math and Medications 770
20:2 Positioning a Patient 725 A: Using Roman Numerals 773
20:3 Screening for Vision Problems 732 B: Converting Metric Measurements 774
20:4 Assisting with Physical Examinations 737 C: Converting Household (English)
A: Eye, Ear, Nose, and Throat Measurements 775
Examination 741 Today’s Research: Tomorrow’s Health Care 776
B: Assisting with a Gynecological Summary 777
Examination 743 Internet Searches 777
C: Assisting with a General Physical Review Questions 777
Examination 745
Contents ix
CHAPTER 21 Nurse Assistant Skills 779

Objectives 779 21:6 Feeding a Patient 855
Key Terms 780 21:7 Assisting with a Bedpan/Urinal 859
Career Highlights 781 A: Assisting with a Bedpan 860
21:1 Admitting, Transferring, B: Assisting with a Urinal 863
and Discharging Patients 782 21:8 Providing Catheter and Urinary
A: Admitting the Patient 784 Drainage Unit Care 864
B: Transferring the Patient 786 A: Providing Catheter Care 868
C: Discharging the Patient 788 B: Emptying a Urinary-Drainage Unit 870
21:2 Positioning, Turning, Moving, 21:9 Providing Ostomy Care 872
and Transferring Patients 790 21:10 Collecting Stool/Urine Specimens 877
A: Aligning the Patient 793 A: Collecting a Routine Urine
B: Moving the Patient Up in Bed 795 Specimen 880
C: Turning the Patient Away B: Collecting a Midstream Urine
to Change Position 797 Specimen 882
D: Turning the Patient Inward C: Collecting a 24-Hour Urine
to Change Position 799 Specimen 884
E: Sitting Up to Dangle 801 D: Collecting a Stool Specimen 886
F: Transferring a Patient to a Chair E: Preparing and Testing a Hemoccult
or Wheelchair 803 Slide 887
G: Transferring a Patient to a Stretcher 806 21:11 Enemas and Rectal Treatments 889
H: Using a Mechanical Lift to Transfer A: Giving a Tap-Water, Normal Saline,
a Patient 809 or Soap-Solution Enema 890
21:3 Bedmaking 812 B: Giving a Disposable Enema 894
A: Making a Closed Bed 813 C: Giving an Oil-Retention Enema 896
B: Making an Occupied Bed 817 D: Inserting a Rectal Tube 898
C: Opening a Closed Bed 820 21:12 Applying Restraints 900
D: Placing a Bed Cradle 821 A: Applying Limb Restraints 902
21:4 Administering Personal Hygiene 823 B: Applying a Jacket Restraint 904
A: Providing Routine Oral Hygiene 827 21:13 Administering Preoperative and
B: Cleaning Dentures 828 Postoperative Care 906
C: Giving Special Mouth Care 830 A: Shaving the Operative Area 910
D: Administering Daily Hair Care 832 B: Administering Preoperative Care 912
E: Providing Nail Care 834 C: Preparing a Postoperative Unit 913
F: Giving a Backrub 835 D: Applying Surgical Hose 915
G: Shaving a Patient 838 21:14 Applying Binders 917
H: Changing a Patient’s Gown or 21:15 Administering Oxygen 919
Pajamas 840 21:16 Giving Postmortem Care 925
I: Giving a Complete Bed Bath 842 Today’s Research: Tomorrow’s Health Care 928
J: Helping a Patient Take a Tub Bath Summary 928
or Shower 847 Internet Searches 929
21:5 Measuring and Recording Intake Review Questions 929
and Output 849
x CONTENTS
CHAPTER 22 Physical Therapy Skills 930

Objectives 930 D: Ambulating a Patient Who Uses
Key Terms 931 a Walker 953
Career Highlights 931 22:3 Administering Heat/Cold Applications 954
22:1 Performing Range-of-Motion (ROM) A: Applying an Ice Bag or Ice Collar 957
Exercises 932 B: Applying a Warm-Water Bag 959
22:2 Ambulating Patients Who Use Transfer C: Applying a Aquathermia Pad 961
(Gait) Belts, Crutches, Canes, D: Applying a Moist Compress 963
or Walkers 940 E: Administering a Sitz Bath 965
A: Ambulating a Patient with Today’s Research: Tomorrow’s Health Care 967
a Transfer (Gait) Belt 945 Summary 967
B: Ambulating a Patient Who Uses Internet Searches 967
Crutches 947 Review Questions 968
C: Ambulating a Patient Who Uses
a Cane 950
CHAPTER 23 Business and Accounting Skills 969

23:1 A: Filing Records 970 Internet Searches 1020
23:1 B: Filing Records Using the Review Questions 1021
Alphabetical or Numerical System 973
23:2 Using the Telephone 977
Appendix A: Career and Technical Student
23:3 Scheduling Appointments 983
Organizations (CTSOs) 1022
23:4 Completing Medical Records
and Forms 987 Appendix B: Correlation to National
23:5 Composing Business Letters 993 Health Care Skill Standards 1026
23:6 Completing Insurance Forms 999 Appendix C: Metric Conversion Charts 1027
23:7 Maintaining a Bookkeeping System 1007 Appendix D: 24-Hour Clock (Military Time)
23:8 Writing Checks, Deposit Slips, Conversion Chart 1029
and Receipts 1013
Glossary 1030
A: Writing Checks 1015
B: Writing Deposit Slips 1017 References 1052
C: Writing Receipts 1018 Index 1060
PREFACE
Diversified Health Occupations, seventh edition, was written to pro-

vide the beginning student in health occupations with the basic
entry-level knowledge and skills required for a variety of health care
careers. Although each specific health care career requires special-
ized knowledge and skills, some knowledge and skills are applicable
to many different health careers. In short, this book was developed
to provide some of the core knowledge and skills that can be used in
many different fields.
ORGANIZATION OF TEXT
Diversified Health Occupations, seventh edition, is divided into two
main parts. Part 1 provides the student with the basic knowledge and
skills required for many different health care careers. Part 2 intro-
duces the student to basic entry-level skills required for some spe-
cific health care careers. Each part is subdivided into chapters.
Chapter Organization
Each chapter has a list of objectives and a list of key terms (with
pronunciations for more difficult words). For each skill included in
the text, both the knowledge necessary for the skill and the proce-
dure to perform the skill are provided. By understanding the princi-
ples and the procedure, the student will develop a deeper
understanding of why certain things are done and will be able to
perform more competently. Procedures may vary slightly depending
on the type of agency and on the kind of equipment and supplies
used. By understanding the underlying principles, however, the stu-
dent can adapt the procedure as necessary and still observe correct
technique.
Information Sections (Textbook): The information sections provide
the basic knowledge the student must acquire. These sections explain
why the knowledge is important, the basic facts regarding the par-
ticular topic, and how this information is applied in various health
careers. Most information sections refer the student to the assign-
ment sheets found in the student workbook.
xii PREFACE
Assignment Sheets (Workbook): After students ♦ The text material covers the National Health
have read an information section, they are Care Skills Standards, helping instructors
instructed to go to the corresponding assignment implement the curriculum elements of this
sheet. The assignment sheets allow them to test important document. A new appendix pro-
their comprehension and to return to the infor- vides a table showing the correlation of chap-
mation section to check their answers. This ters in the book to the National Health Care
enables them to reinforce their understanding of Skill Standards.
the information presented prior to moving on to
another information section.
♦ Mandates of the Health Insurance Portability
and Accountability Act (HIPAA) have been
Procedure Sections (Textbook): The procedure
incorporated throughout the textbook to
sections provide step-by-step instructions on how
emphasize the student’s responsibilities in
to perform specific procedures. The student follows
regard to this act.
the steps while practicing the procedures. Each
procedure begins with a list of the necessary equip- ♦ Internet search topics are at the end of each
ment and supplies. Note, Caution, and Checkpoint chapter to encourage the student to explore
may appear within the procedure. Note urges care- the Internet to obtain current information on
ful reading of the comments that follow. These com- the many aspects of health care.
ments usually stress points of knowledge or explain ♦ Review questions are at the end of each chapter
why certain techniques are used. Caution indicates to enable the student to test his or her knowl-
that a safety factor is involved and that students edge of information provided in the chapter.
should proceed carefully while doing the step in
♦ Career information has been updated and is
order to avoid injuring themselves or a patient.
stressed throughout the textbook to provide
Checkpoint alerts students to ask the instructor to
current information on a wide variety of health
check their work at that point in the procedure.
care careers. Careers have been organized
Checkpoints are usually located at a critical stage.
according to the National Career Clusters. In
Each procedure section refers the student to a spe-
addition, careers in forensic medicine and
cific evaluation sheet in the workbook.
biotechnology have been added.
Evaluation Sheets (Workbook): Each evaluation
sheet contains a list of criteria on which the stu- ♦ Additional emphasis has been placed on cul-
dent’s performance will be tested after they have tural diversity, technological advances, legal
mastered a particular procedure. When a student responsibilities, new federal legislation per-
feels he or she has mastered a particular proce- taining to health care providers, infection con-
dure, he or she signs the evaluation sheet and trol standards, and safety.
gives it to the instructor. The instructor can grade ♦ Various icons have been included throughout
the students’ performance by using the listed cri- the textbook. These icons denote the integra-
teria and checking each step against actual per- tion of academics, such as math, science, and
formance. communication; occupational safety issues,
Because regulations vary from state to state such as standard precautions and OBRA re-
regarding which procedures can be per- quirements; and workplace readiness issues
formed by a student in health science technology such as career, legal, and technology informa-
education, it is important to check the specific tion. An icon key similar to the one below can
regulations for your state. A health care worker be found on the opening page of every chapter.
should never perform any procedure without The icons and their meaning are as follows:
checking legal responsibilities. In addition, a stu-
Observe Standard Precautions
dent should perform no procedure unless the
student has been properly taught the procedure
Safety—Proceed with Caution
and has been authorized to perform it.
Math Skill
Added Features
Science Skill
♦ More than 240 new photos and illustrations
have been added to enhance learning and
Communications Skill
clarify technical content.
Preface xiii
Instructor’s Check—Call Instructor at This and safeguards that must be taken to protect
Point computer security.
OBRA Requirement—Based on Federal Law ♦ A free StudyWARE™ CD-ROM is packaged

with the book. The software is designed to
Legal Responsibility offer additional review of concepts. See “How
to Use the Diversified Health Occupations,
Career Information Seventh Edition, StudyWARE™” for details.
Technology
EXTENSIVE TEACHING
AND LEARNING
Enhanced Content PACKAGE
Diversified Health Occupations, seventh edition,
♦ Vital, updated information on standard pre-
has a complete and specially designed supple-
cautions, OBRA requirements, and transmis-
ment package to enhance student learning and
sion-based isolation techniques have been
workplace preparation. It is also designed to
included.
assist instructors in planning and implementing
♦ A new section on bioterrorism provides infor- their instructional programs for the most effi-
mation to make students aware of this con- cient use of time and resources. The package
stant threat and to describe methods used to contains:
prevent and manage its consequences.
♦ The information on viruses has been expanded
to include new viruses that can become po- Diversified Health Occupations
tential sources of epidemics and pandemics. Teacher’s Resource Kit
New emphasis is placed on infection con-
trol methods to prevent epidemics and/or A complete guide to implementing a Diversified
pandemics. Health Occupations course. The kit explains how
to apply content to applied academics and the
♦ The section on cardiopulmonary resuscita- National Health Care Skill Standards. This kit is
tion has been revised to meet the American provided as a three-ring binder with convenient
Heart Association’s new 2005 standards for tabs to easily locate the resources needed for spe-
CPR for health care professionals. cific classroom support. It provides:
♦ New nutritional guidelines from the U.S. ♦ Classroom Management Activities
Department of Agriculture have been incor-
porated into the nutrition chapter. Instruc- ♦ Lesson Plans
tions are provided for using My Pyramid to ♦ Ready-to-Use Tests and Quizzes
plan a healthy diet.
♦ Classroom Activities
♦ A new section on weight management dis-
cusses how to calculate ideal weight, how to ♦ Internet Activities
lose or gain weight, and how to make food ♦ Leadership Development Activities
choices that will maintain a healthy weight.
♦ Transparency Masters to reinforce learning in
♦ Mandates of the Health Insurance Portability a visual format
and Accountability Act (HIPAA) have been
incorporated throughout the textbook to
emphasize how it affects insurance portability Diversified Health
and confidentiality of patient information.
Occupations, Seventh Edition,
♦ A new section on Internet computer safety
and security explains ways to protect com-
Instructor’s Manual
puter hardware and software, methods used Provides easy-to-find answers to questions found
to maintain confidentiality of information, in the Student Workbook.
xiv PREFACE
Diversified Health WebTutor to Accompany

Occupations, Seventh Edition, Diversified Health
Student Workbook Occupations, Seventh Edition
This workbook, updated to reflect the Diversified WebTutor is an Internet-based course manage-
Health Occupations, seventh edition text, con- ment and delivery system designed to accom-
tains perforated, performance-based assignment pany the text. Its content is available for use in
and evaluation sheets. The assignment sheets either WebCT or Blackboard. Available to supple-
help students review what they have learned. The ment on-site delivery or as the course manage-
evaluation sheets provide criteria or standards ment platform for an online course, WebTutor
for judging student performance for each proce- contains:
dure in the text.
♦ Web links that offer links to other sites that
contain additional information pertinent to
Diversified Health Occupations topics being discussed
Electronic Classroom Manager ♦ Learning links that offer students a short

assignment using the Internet
An electronic package for teachers, this innova-
tive CD-ROM provides a wealth of tools to sup- ♦ Flashcards for review of key terms
port and manage the course. Components ♦ Online quizzes for each chapter
include:
♦ Plus a host of other great features
♦ Customizable Computerized Test Bank on the
ExamView platform providing over 1,800 ques-
tions and answers directly tied to the textbook
in multiple choice, true/false, matching, and Diversified Health
short answer format. Occupations, Seventh Edition,
♦ PowerPoint Presentation with over 900 slides Online Companion
supporting the text for use in classroom lec-
tures. An online companion is available to accompany
the text that includes valuable information for
♦ Electronic Instructor’s Manual in PDF format both the student and instructor.
providing electronic access to the printed
For the student:
Diversified Health Occupations Instructor’s
Manual. ♦ PowerPoint presentation of important con-
♦ Image Library providing a searchable data- cepts
base of electronic versions of the Transpar- ♦ StudyWARETM software that is designed to
ency Masters found in the Diversified Health offer additional review of concepts
Occupations Teacher’s Resource Kit.
♦ Evaluation Checklists from the Student Work-
♦ Multimedia animations narrating difficult to book
visualize anatomical and physical processes,
including The Anatomy of a Cell, The Process ♦ Link to Audio Podcasts of medical termi-
of Hearing, Blood Flow through the Heart, and nology
much more. ♦ Fourteen Animations that make anatomy and
♦ Links to the Online Companion and more. physiology concepts come alive
Preface xv
The Online Companion tools for the instruc- Health Occupations in the State of Ohio and the
tor are on a password-protected site. Tools Diversified Health Occupations Instructor of the
include: Year Award for the State of Ohio. Mrs. Simmers
is retired and lives with her husband in Venice,
♦ Online Instructor’s Manual with answers to
Florida. The author is pleased to announce that
the Student Workbook
her twin daughters will now be assisting with the
♦ PowerPoint Presentation to help you manage revisions of this textbook.
your classroom presentation Karen Simmers-Nartker graduated from Kent
♦ Computerized Test Bank with more than 1,800 State University, Ohio, with a Bachelor of Science
questions. degree in Nursing. She has been employed as a
♦ Evaluation Checklist from the Student Work- telemetry step-down, medical intensive care,
book surgical intensive care, and neurological inten-
sive care nurse. She is currently employed as a
♦ Conversion Grids to help you move from the shift coordinator in an open-heart intensive care
6th edition to the 7th edition of Diversified unit. She has obtained certification from the
Health Occupations Emergency Nurses Association for the Trauma
♦ Fourteen Animations that make anatomy and Nursing Core Course (TNCC) and from the Amer-
physiology concepts come alive ican Heart Association for Advanced Cardiac Life
Support (ACLS). In her current position as charge
To access the companion, go to
nurse in her ICU, she coordinates patient care
http://www.delmarlearning/companions.com.
and staff assignments; manages interpersonal
conflicts among staff and/or patients and family
About the Authors members; is responsible for ensuring quality care
Louise Simmers received a Bachelor of Science to meet the diverse needs of patients and/or fam-
degree in nursing from the University of Maryland ily; actively participates in inservices to evaluate
and an MEd from Kent State University. She has new equipment, medications, hospital services
worked as a public health nurse, medical-surgical and supplies; and teaches and mentors newly
nurse, charge nurse in a coronary-intensive care employed nurses.
unit, instructor of practical nursing, and health Sharon Simmers-Kobelak graduated from
occupations teacher and school-to-work coordi- Miami University, Ohio, with a Bachelor of Busi-
nator at the Madison Comprehensive High School ness Administration degree. She works in the
in Mansfield, Ohio. She is a member of the Univer- educational publishing industry. She has experi-
sity of Maryland Nursing Alumni Association, ence assisting instructors at private career schools
Sigma Theta Tau, Phi Kappa Phi, National Educa- in finding appropriate materials for classroom
tion Association, and Association for Career and instruction. Sharon also provides inservice train-
Technical Education (ACTE), and is a volunteer ing for instructors on how to utilize the instructor
worker for the Red Cross. Mrs. Simmers received and student resources in the most productive
the Vocational Educator of the Year Award for manner.
This page intentionally left blank
HOW TO USE
Objectives CHAPTER 16 First Aid
Review these goals before you begin reading a

chapter to help you focus your study. Then, when
you have completed the chapter, go back and Chapter Objectives
review these goals to see if you have grasped the After completing this chapter,
you should be able to:
Observe Standard
◆ Demonstrate cardiopulmonary resuscitation
key points of the chapter. Precautions
for one-person rescue, two-person rescue,
infants, children, and obstructed-airway
Instructor’s Check—Call victims
Icons
Instructor at This Point
◆ Describe first aid for
—bleeding and wounds
Safety—Proceed with —shock
Caution —poisoning
—burns
—heat exposure
Icons are used throughout the text to highlight OBRA Requirement—Based
on Federal Law —cold exposure
—bone and joint injuries, including fractures
—specific injuries to the eyes, head, nose, ears,
specific pieces of information. This icon key is Math Skill chest, abdomen, and genital organs
—sudden illness including heart attack, stroke,
presented to reinforce the meaning of the icons. Legal Responsibility

fainting, convulsions, and diabetic reactions
◆ Apply dressings and bandages, observing all
safety precautions and using the circular,
Science Skill spiral, figure-eight, and recurrent, or finger
wrap
Career Information ◆ Define, pronounce, and spell all key terms
Technology
30216_16_Ch16_448-527.indd 448 1/11/08 1:21:54 PM
KEY TERMS
Key Terms
acquired immune deficiency contaminated pathogens (path⬘-oh-jenz⬙)
syndrome (AIDS) disinfection personal protective
Key Terms highlight the critical vocabu-
aerobic droplet precautions equipment (PPE) lary words you will need to learn.
airborne precautions endogenous portal of entry
anaerobic epidemic portal of exit Pronunciations are also included for the
antisepsis (ant⬙-ih-sep⬘-sis) exogenous protective (reverse) isolation harder-to-pronounce words. These
asepsis (a-sep⬘-sis) fomites protozoa (pro-toe-zo⬘-ah)
autoclave fungi (fun⬘-guy) reservoir terms are highlighted within the text
bacteria helminths rickettsiae (rik-et⬘-z-ah) where they are defined. You will also
bioterrorism hepatitis B standard precautions
causative agent hepatitis C sterile find most of these terms listed in the
cavitation microorganism (my-crow- sterile field glossary section. Use this listing as part
(kav⬙-ih-tay⬘-shun) or⬘-gan-izm) sterilization
chain of infection mode of transmission susceptible host of your study and review of critical
chemical disinfection nonpathogens transmission-based terms.
clean nosocomial isolation precautions
communicable disease opportunistic ultrasonic
contact precautions pandemic viruses
xviii HOW TO USE
TODAY’S RESEARCH: TOMORROW’S HEALTH CARE

Today’s Research:
A bravery gene?
Anxiety and fear have been felt by every human being. However, some individuals are so
anxious or fearful they are not able to function within society. For example, individuals with
agoraphobia have an abnormal fear of being helpless in a situation from which they cannot
Tomorrow’s
escape, so they stay in an environment in which they feel secure. Many agoraphobic people
never leave their homes; they avoid all public or open places. Scientists are not really certain
how fear works in the brain, so conditions such as these are difficult to treat.
Health Care
Recently, scientists working with mice found that by removing a single gene, they could
turn normally cautious animals into brave animals that were more willing to explore an Today’s Research: Tomorrow’s Health Care
unknown territory and were less intimidated by dangers. By analyzing brain tissue, scien- boxes are located in each chapter. These
tists located a gene in a tiny prune-shaped region of the brain called the amygdala, an area
of the brain that is extremely active when animals or humans are afraid or anxious. This commentaries help you learn about the
gene produces a protein called stathmin, which is highly concentrated in the amygdala but
very hard to detect in other areas of the brain. Scientists removed this stathmin gene and many different types of research occurring
bred a line of mice that were all missing this gene. Tests showed that this breed of mice was
twice as willing to explore unknown territories as unaltered mice. In addition, if the mice
today. If the research is successful, it may
were trained to expect a small electrical shock after being presented with a stimulus such as lead to possible cures and or better meth-
a sound or sight, this group of mice did not seem as fearful when the sound or sight was
given. Researchers are theorizing that stathmin helps form fearful memories in the amyg- ods of treatment in the future for a wide
dala of the brain, the area where unconscious fears seemed to be stored. If the production of
stathmin could be halted or inhibited by medication, it is possible that fears would not be range of diseases and disorders. These
stored as unconscious memories. This would greatly decrease an individual’s anxieties
because unconscious fears are a major cause of anxiety. Think of all of the people whose
boxes of information also highlight the fact
lives are affected by anxiety and fear. If their anxieties and fears could be decreased or elim- that health care changes constantly
inated, they could lead normal healthy lives.
because of new ideas and technology.
Career CAREER HIGHLIGHTS
Highlights Physical therapist assistants provide treatment to improve mobility and prevent or limit
permanent disability of patients with disabling injuries or disease. They are important mem-
bers of the health care team. They work under the supervision of a physical therapist who
has a master’s degree from an accredited program and is licensed (required in all states).
Career Highlights appear in Special Most physical therapist assistants have an associate’s degree from an accredited program
and an internship. Licensure is required in most states.
Health Care Skills chapters. By reading The duties of physical therapist assistants vary but usually include performing exercises;
and understanding the material pre- providing ultrasound or electrical stimulation treatments; administering heat, cold, or moist
applications; ambulating patients with assistive devices; and informing the physical therapist
sented in these boxes, you will learn the of patient’s response and progress. In addition to the knowledge and skills presented in this
chapter, physical therapist assistants must also learn and master skills such as:
educational requirements of each
◆ Presenting a professional ◆ Comprehending anatomy, ◆ Promoting good nutrition
profession, potential places of employ- appearance and attitude physiology, and and a healthy lifestyle to
ment, and additional tasks you may ◆ Obtaining knowledge
pathophysiology with an maintain health
regarding health care emphasis on the skeletal, ◆ Utilizing computer skills
have to perform that are not specifically delivery systems, muscular, nervous, and
circulatory systems ◆ Cleaning and maintaining
discussed within the chapter. organizational structure, equipment
and teamwork ◆ Observing all safety
precautions ◆ Ordering and maintaining
◆ Meeting all legal
supplies and materials
30216_17_Ch17_528-549.indd 548 responsibilities ◆ Practicing all principles of
1/11/08 1:23:31 PM
infection control ◆ Performing administrative
◆ Communicating
duties such as answering
effectively ◆ Administering first aid
the telephone, scheduling
◆ Being sensitive to and
and cardiopulmonary appointments,
respecting cultural resuscitation completing insurance
diversity forms, and maintaining
◆ Learning medical
patient records
terminology
RELATED HEALTH CAREERS

30216_22_Ch22_930-968.indd 931
Related Health 1/11/08 1:24:32 PM
NOTE: A basic knowledge of human anatomy and physiology is essential for almost every
health care provider. However, some health careers are related to specific body systems. As
each body system is discussed, examples of related health careers are listed. The following
Careers
health career categories require knowledge of the structure and function of the entire human
body and will not be listed in specific body system units. Related Health Careers appear in
Chapter 7, Anatomy and Physiology. By
◆ Athletic Trainer ◆ Medical Assistant ◆ Physician Assistant
◆ Emergency Medical ◆ Medical Illustrator ◆ Physician
reviewing the information presented in
Careers ◆ Nursing Careers ◆ Surgical Technologist these boxes, you will relate specific
◆ Medical Laboratory health careers to specific body systems.
◆ Pharmacy Careers
Careers
30216_07_Ch07_140-234.indd 141 1/11/08 1:46:19 PM

How to Use xix
13:1 INFORMATION
Information Using Body Mechanics
Sections To prevent injury to yourself and others while

working in the health field, it is important that
you observe good body mechanics.
Body mechanics refers to the way in which
Information sections explain the basic the body moves and maintains balance while
facts of the topic, why you would need making the most efficient use of all its parts. Basic
rules for body mechanics are provided as guide-
this information, and how the informa- lines to prevent strain and help maintain muscle
strength.
tion is applied to various health care There are four main reasons for using good
fields. body mechanics:
♦ Muscles work best when used correctly.
♦ Correct use of muscles makes lifting, pulling,
and pushing easier.
♦ Correct application of body mechanics pre-
vents unnecessary fatigue and strain, and
saves energy.
vents injury to self and others.
Eight basic rules of good body mechanics FIGURE 13-1 Maintain a broad base of support
include: by keeping the feet 8–10 inches apart.
♦ Maintain a broad base of support by keep-
ing the feet 8–10 inches apart, placing one foot
slightly forward, balancing weight on both ♦ Use the weight of your body to help push or
feet, and pointing the toes in the direction of pull an object. Whenever possible, push, slide,
movement (figure 13-1). or pull rather than lift.
♦ Bend from the hips and knees to get close to ♦ Carry heavy objects close to the body. Also,
an object, and keep your back straight (figure stand close to any object or person being
13-2). Do not bend at the waist. moved.
♦ Use the strongest muscles to do the job. The ♦ Avoid twisting your body as you work. Turn
larger and stronger muscles are located in the with your feet and entire body when you
shoulders, upper arms, hips, and thighs. Back change direction of movement.
muscles are weak. ♦ Avoid bending for long periods.
30216_13_Ch13_333-349.indd 334 1/11/08 1:25:44 PM
PROCEDURE 15:2B
mouth. Wait at least 15 minutes if the
Procedures
Measuring and
Recording Oral
Temperature 5.
patient says “yes” to your question.
Remove the clean thermometer by the
upper end. Use a clean tissue or dry cot-
Sections
ton ball to wipe the thermometer from Procedures sections provide step-by-
Equipment and Supplies stem to bulb.
step instructions on how to perform
Oral thermometer, plastic sheath (if used), NOTE: If the thermometer was soaking
holder with disinfectant solution, tissues or in a disinfectant, rinse first in cool the procedure outlined in the Informa-
dry cotton balls, container for used tissues, water.
watch with second hand, soapy cotton balls,
tion section. Practice these procedures
CAUTION: Hold the thermometer se-
disposable gloves, notepaper, pencil/pen curely to avoid breaking. until you perform them correctly and
Procedure 6. Read the thermometer to be sure it reads proficiently.
96°F (35.6°C) or lower. Check carefully
for chips or breaks.
1. Assemble equipment.
CAUTION: Never use a cracked ther-
2. Wash hands and put on gloves.
mometer because it may injure the
CAUTION: Follow standard precautions patient.
for contact with saliva or the mucous
7. If a plastic sheath is used, place it on the
membrane of the mouth.
thermometer.
3. Introduce yourself. Identify the patient.
8. Insert the bulb under the patient’s
Explain the procedure.
tongue, toward the side of the mouth
4. Position the patient comfortably. Ask (figure 15-12). Ask the patient to hold it
the patient if he/she has eaten, has had in place with the lips, and caution
hot or cold fluids, or has smoked in the against biting it.
past 15 minutes.
NOTE: Check to be sure patient’s mouth
NOTE: Eating, drinking liquids, or smok- is closed.
ing can affect the temperature in the
30216_15_Ch15_412-447.indd 421 1/11/08 1:26:29 PM
30216_00_FM_i-xxix.indd xix
xx HOW TO USE
Full-Color Photos and Illustrations

Illustrations are presented in full color that demonstrate important health care concepts, including the
inner workings of the body. Use these illustrations for review while studying.
Full-color photos are used throughout the text to illustrate important techniques you will be required to
know and demonstrate when working within a health care field.
Sweat pore
Hair shaft
Dermal papilla
Sensory nerve
Stratum ending for touch
corneum
Stratum Epidermis
lucidum
Stratum
Stratum spinosum Dermis
germinativum Stratum
basale
Arrector pili muscle
Sebaceous (oil) gland
Subcutaneous
Hair follicle fatty tissue
(hypodermis)
Papilla of hair
FIGURE 14-20A To remove the first glove,
use a gloved hand to grasp the outside of the
Nerve fiber Vein
glove on the opposite hand. Pull the glove down
Artery and turn it inside out while removing it.
Nerve
Sweat gland
Pacinian corpuscle
FIGURE 7-9 Cross-section of skin.
Internet INTERNET SEARCHES

30216_14_Ch14_350-411.indd
Use the suggested search engines in Chapter 12:4

369 REVIEW QUESTIONS
1. List the classifications of bacteria by shape and
Searches of this textbook to search the Internet for addi-

tional information on the following topics:
1. Organizations regulating infection control: find
give two (2) examples of diseases caused by
each class.
2. Draw the chain of infection and identify three
the organization sites for the Occupational
Internet Searches can enhance your Safety and Health Administration (OSHA),
(3) ways to break each section of the chain.
comprehension of the chapter informa- Centers for Disease Control and Prevention 3. Differentiate between antisepsis, disinfection,
(CDC), National Center for Infectious Diseases and sterilization.
tion by offering you the chance to read (NCID), and the Hospital Infection Control 4. Develop a plan showing at least five (5) ways
Practices Advisory Committee (HICPAC) to
information on the chapter topics. obtain information on regulations governing
you can protect yourself and your family from
a bioterrorism attack.
infection control
Review 2. Microbiology: search for specific information

on bacteria (can also search for specific types
such as Escherichia coli), protozoa, fungi,
5. List eight (8) times the hands must be washed.
6. Name the different types of personal protective
equipment (PPE) and state when each type
Questions rickettsiae, and viruses

3. Diseases: obtain information on the method of
transmission, signs and symptoms, treatment,
must be worn to meet the requirements of
standard precautions.
7. What level of infection control is achieved by
Review Questions enhance your com- and complications for diseases such as hepati- an ultrasonic cleaner? chemicals? an auto-
tis B, hepatitis C, acquired immune deficiency clave?
prehension of chapter content. After syndrome, and specific diseases listed by the 8. Name three (3) methods that can be used to
you have completed the chapter discussion on microorganisms in this unit place sterile items on a sterile field. Identify the
4. Infections: research endogenous infections, types of items that can be transferred by each
reading, try to answer the review exogenous infections, nosocomial infections, method.
questions at the end of the chapter. If and opportunistic infections
you find yourself unable to answer the

questions, go back and review the
chapter again.
30216_07_Ch07_140-234.indd 152 1/11/08 1:44:38 PM
30216_14_Ch14_350-411.indd 411 1/11/08 1:46:54 PM

HOW TO USE
DIVERSIFIED HEALTH
OCCUPATIONS,
SEVENTH EDITION,
STUDYWARE™
MINIMUM SYSTEM
REQUIREMENTS
♦ Operating systems: Microsoft Windows 2000, Windows XP, Win-
dows Vista
♦ Processor: Minimum required by operating system
♦ Memory: Minimum required by operating system
♦ Screen resolution: 800 ⫻ 600 pixels
♦ Color depth: 16-bit color (thousands of colors)
♦ Macromedia Flash Player 9. The Macromedia Flash Player is free,
and can be downloaded from http://www.adobe.com/products/
flashplayer/
INSTALLATION
INSTRUCTIONS
1. Insert disc into CD-ROM player. Diversified Health Occupations,
Seventh Edition, StudyWARETM installation program should start
up automatically. If it does not, go to step 2.
2. From My Computer, double-click on the icon for the CD drive.
3. Double-click on the setup.exe file to start the program.
TECHNICAL SUPPORT
Telephone: 1-800-648-7450; 8:30 A.M.–5:30 P.M. Eastern Time
Fax: 1-518-881-1247
E-mail: delmar.help@cengage.com
StudyWARE™ is a trademark used herein under license.
Microsoft® and Windows® are registered trademarks of the Microsoft
Corporation.
Pentium® is a registered trademark of the Intel Corporation.
xxii HOW TO USE
GETTING STARTED
The StudyWARETM software is designed to enhance your learning. As
you study each chapter in the text, be sure to explore the activities in
the corresponding chapter in the software. Use StudyWARETM as
your own private tutor to help you learn the material in the text.
Getting started is easy. Install the software by inserting the CD and
following the on-screen instructions. Enter your first and last name so
that the software can store you quiz results. Then choose a chapter
from the menu and take a quiz or explore one of the activities.
Menus
You can access any of the menus from wherever
you are within the program. The menus include
Quizzes, Scores, Activities, and Animations.
How to Use xxiii
Quizzes
Quizzes include multiple choice and fill-in questions. You
can take the quizzes in both Practice Mode and Quiz Mode.
Use Practice Mode to improve your mastery of the material.
You have multiple tries to get the answers correct. Instant
feedback tells you whether you are right or wrong—and
helps you learn quickly by explaining why an answer was
correct or incorrect. Use Quiz Mode when you are ready to
test yourself and keep a record of your scores. In Quiz Mode,
you have one try to get the answers right, but you can take
each Quiz as many times as you want.
Scores
You can view your last scores for each quiz
and print out your results to hand in to your
instructor.
xxiv HOW TO USE
Activities
Activities include Flashcards, Crossword, Hang-
man, Ordering and Sorting, and a Jeopardy!-style
Championship Game. Have fun while increasing
your knowledge.
Animations
Animations help you visualize concepts related to
pathological conditions and anatomy.
ACKNOWLEDGMENTS
This seventh edition of Diversified Health Occupations is dedicated

to my grandchildren, Hayden Michael Kobelak, Kaleigh Ann Nartker,
Kyla Ann Kobelak, Jesse Louise Nartker, and Brady Wayne Nartker!
Our grandchildren help keep us young and bring so much joy and
pleasure into our lives.
The author would like to thank everyone who participated in the
development of this text, including
Nancy L. Raynor, former Chief Consultant, Head Occupations
Education, State of North Carolina, who served as a consultant
and major mentor in the initial development of this textbook
Dr. Charles Nichols. Department Head, and Ray Jacobs, Teacher
Educator, Kent State University
Nancy Webber, RN, Diversified Health Occupations Instructor
Each person who consented to be a subject in the photographs
Administrative staff at Madison Comprehensive High School
Carolynn Townsend, Lisa Shearer Cooper, Donna Story, and
Dorothy Fishman, who contributed chapter information
Kathryn G. Cutlip, Health and Safety Services Director at Rich-
land County Red Cross, who reviewed and contributed informa-
tion for the First Aid Chapter
Sharon Logan, a true friend and health care professional, who
never hesitates to review new material, research information,
critique the manuscript, and offer encouragement
The author and Delmar would like to thank those individuals
who reviewed the manuscript and offered suggestions, feedback,
and assistance. The text has been improved as a result of the review-
ers’ helpful, insightful, and creative suggestions. Their work is greatly
appreciated.
Becky Carter
Health Science Instructor
Charlotte, North Carolina
xxvi ACKNOWLEDGMENTS
Eleanore Cross Linda Stanhope

Health Science Instructor Texas State Curriculum Writer
Scotland High School Health Science Instructor
Laurinburg, North Carolina Amarillo, Texas
Beverly Fenley Kathy Turner
Health Science Technology Instructor Health Occupations Consultant
Academy of Irving North Carolina Department of Public
Irving, Texas Instruction
Cary, North Carolina
Christine Glass
ROP Instructor at Weber Institute Debra Ziegler, RN, BS
Stockton Unified School District Health Sciences Instructor
Lodi, California Ralston High School
Ralston, Nebraska
Natalie Kelly
Health Science Instructor The author also wishes to thank the following
Hardaway High School companies, associations, and individuals for
Columbus, Georgia information and/or illustrations.
Julee T. Kristeller, RN A-dec, Inc.
Health Occupations Instructor
Gray’s Creek High School American Cancer Society
Hope Mills, North Carolina American Optometric Association
Diane Sharp Becton Dickinson
Kentucky Department of Education
Career and Technical Education Timothy Berger, MD
Frankfort, Kentucky Bruce Black, MD
Lara Skaggs Boehringer Mannheim
State Program Manager
Health Careers Education Brevis Corporation
Oklahoma Department of CareerTech
Briggs Corporation
Education
Stillwater, Oklahoma Marcia Butterfield
Acknowledgments xxvii
Carson’s Scholar Fund Omron Healthcare

Centers for Disease Control and Prevention Pfizer
CIBA Pharmaceutical Company Philips Electronic Instruments
Sandy Clark Phoenix Society of Burn Survivors, Inc
The Clorox Company Photodisc
Control-o-fax Office Systems Poly-Medco
Exergen Corporation Professional Innovations
Food and Drug Administration (FDA) Patrick Reineck, DDS
Deborah Funk, MD Sage Products, Inc.
G.E. Medical Systems Salk Institute
Health Occupations Students of America Robert A. Silverman
HemoCue® SkillsUSA
Hill-Rom Smead Manufacturing
Hollister Incorporated Spacelabs Medical, Inc.
Hu-Friedy Manufacturing Company Ron Stram, MD
J.T. Posey Company Sunrise Medical
Kardex Systems 3M Company
Kerr Corporation U.S. Army
Medline Industries U.S. Department of Agriculture
Michigan Pharmacist Association U.S. Postal Systems
Miltex Instrument Company W.A. Foote Memorial Hospital
National Eye Institute
National Hospice and Palliative Care
Organization
PART 1 Basic Health Care
Concepts & Skills
Welcome to the world of health science technology educa-

tion. You have chosen a career in a field that offers endless
opportunities. If you learn and master the knowledge and
skills required, you can find employment in any number of
rewarding occupations.
There will always be a need for workers in health care
careers because such workers provide services that cannot
be performed by automation or a machine. Thus, although
the future will bring changes, you will always be an impor-
tant part of providing needed care or services.
The material that follows will provide you with a good
start toward your career goal. As you learn to use the infor-
mation presented in the pages that follow, I encourage you to
always continue to learn and to grow. All material is pre-
sented in a manner to make learning as easy as possible.
However, you must still make the effort to achieve the stan-
dards set and to perform to the best of your ability.
I expect that you will find this book different from previ-
ous books that you have used. If you read the pages that
begin each part, you will understand how to use this book. I
think you will enjoy working with it, because it will allow you
to constantly see how much progress you are making. In
addition, it is probably the only book you will have used that
allows you to practice tests or evaluations before you actually
take them.
One final word. You are entering a field that provides one
of the greatest rewards: that of working to assist others.
Although the work is hard at times, you will always have the
satisfaction of knowing that you are helping other people. So,
be proud of yourself. When you learn the concepts and skills
well, you will provide services that are appreciated by all.
Introduction
This part is divided into 17 chapters, each covering several
topics designed to provide you with the basic knowledge and
skills required for many different health careers. Before start-
ing a chapter, read the objectives so you will know exactly what is expected of you. The objectives
identify the competencies you should have mastered upon completing the chapter.
Diversified Health Occupations, 7th edition, has a textbook and a workbook. Each chapter in
the textbook is subdivided into Information sections. At the end of most of these sections is a
statement telling you to go to the workbook to complete an assignment sheet on the information
covered. Some chapters also include Procedure sections, each of which refers you to an evalua-
tion sheet in the workbook. Following are brief explanations of these main components.
1. Information Sections (Textbook): The Information sections provide the basic knowledge you
must acquire. These sections explain why the knowledge is important, the basic facts regard-
ing the particular topic, and how this information is applied in various health careers. Most
Information sections refer you to specific assignment sheets in the workbook. Some Informa-
tion sections provide the basic knowledge you need to perform a given procedure. These
sections explain why things are done, give necessary facts, stress key points that should be
observed, and, again, refer you to specific assignment sheets in the workbook.
2. Assignment Sheets (Workbook): The assignment sheets provide review of the main facts and
information presented in the textbook. After you have read an Information section in the
text, try to answer the questions on the assignment sheet. Refer back to the Information sec-
tion to see if your answers are correct. Let your instructor grade your completed assignment
sheets. Note any changes or corrections. Be sure you understand the information before
moving to another Information section or performing the corresponding procedure.
3. Procedure Sections (Textbook): The Procedure sections provide step-by-step instructions on
how to perform the procedures. Follow the steps while you practice the procedures. Each
procedure begins with a list of the necessary equipment and supplies. On occasion, you will
see any or all of three words within the procedure sections: Note, Caution, and Check-
point. Note means to carefully read the comments following, which usually stress points of
knowledge or explain why certain techniques are used. Caution means that a safety factor is
involved and that you should proceed carefully while doing the step in order to avoid injuring
yourself or the patient. Checkpoint means to ask your instructor to check you at that point
in the procedure. Checkpoints are usually located at critical points in the procedures. Each
procedure section refers you to a specific evaluation sheet in the workbook.
4. Evaluation Sheets (Workbook): Each evaluation sheet contains a list of criteria on which you
will be tested when you have mastered a particular procedure. Make sure that your perfor-
mance meets the standards set. When you feel you have mastered a particular procedure,
sign the evaluation sheet and give it to your instructor. Your instructor will grade you by using
the listed criteria and checking each step against your performance.
In addition to these components, you will also find a list of References at the end of the text-
book. For additional information about the topics discussed, refer to these references.
Finally, you will notice various icons throughout the textbook. Their purpose is to accentuate
particular factors or denote specific types of knowledge. The icons and their meanings are as
follows:
Observe Standard Precautions Math Skill Career Information
Instructor’s Check—Call
Legal Responsibility Communications Skill
Safety—Proceed with Caution Science Skill Technology
OBRA Requirement—Based on
Federal Law
CHAPTER 1 History and Trends
of Health Care
Chapter Objectives
After completing this chapter,
Observe Standard
Precautions
◆ Differentiate between early beliefs about the
cause of disease and treatment and current
beliefs about disease and treatment
◆ Identify at least 10 major events in the history
of health care
◆ Name at least six historical individuals and
Safety—Proceed with
Caution
explain how each one has helped to improve
health care today
◆ Create a time line showing what you believe
OBRA Requirement—Based
on Federal Law
are the 20 most important discoveries in health
care and explain why you believe they are
important
Math Skill
◆ Identify at least five current trends or changes
in health care
Legal Responsibility
◆ Define, pronounce, and spell all key terms
Science Skill
Career Information
Technology
History and Trends of Health Care 3
KEY TERMS
alternative therapies geriatric care outpatient services
complementary therapies holistic health care pandemic
cost containment home health care telemedicine
diagnostic related groups integrative health care wellness
(DRGs) Omnibus Budget
energy conservation Reconciliation Act (OBRA)
NOTE: To further emphasize the Key Terms, they appear in color in the chapter copy. You will notice beginning
in Chapter 3 on page 39 that pronunciations have been provided for the more difficult key terms. The single
accent mark, _⬘_, shows where the main stress is placed when saying the word. The double accent, _⬙_, shows
secondary stress (if present in the word).
1:1 INFORMATION ing the structure of the human body was limited
because most religions did not allow dissection,
History of Health Care or cutting apart of the body. For this reason, ani-
mals were frequently dissected to learn about dif-
Why is it important to understand the history of ferent body parts.
health care? Would you believe that some of the The ancient Egyptians were the first people to
treatment methods in use today were also used in record health records. It is important to remem-
ancient times? In the days before drug stores, ber that many people could not read; therefore,
people used many herbs and plants as both food knowledge was limited to an educated few. Most
and medicine. Many of these herbs remain in use of the records were recorded on stone and were
today. A common example is a medication called created by priests, who also acted as physicians.
morphine. Morphine is made from a poppy plant The ancient Chinese had a strong belief in the
and is used to manage pain. As you review each need to cure the spirit and nourish the entire
period of history, think about how the discoveries body. This form of treatment remains important
have helped to improve the health care you today, when holistic health methods stress treat-
receive today. ing the entire patient—mind, body, and soul.
Hippocrates (ca 460–377 BC), called the
“Father of Medicine,” was one of the most impor-
ANCIENT TIMES tant physicians in ancient Greece (figure 1-1).
The records that he and other physicians created
Table 1-1 lists many of the historical events of helped establish that disease is caused by natural
health care in ancient times. In primitive times, causes, not by supernatural spirits and demons.
the common belief was that disease and illness The ancient Greeks were also among the first to
were caused by evil spirits and demons. Treat- stress that a good diet and cleanliness would help
ment was directed toward eliminating the evil to prevent disease.
spirits. As civilizations developed, changes With knowledge obtained from the Greeks,
occurred as people began to study the human the Romans realized that some diseases were
body and make observations about how it func- connected to filth, contaminated water, and poor
tions. sanitation. They began the development of sani-
Religion played an important role in health tary systems by building sewers to carry away
care. A common belief was that illness and dis- waste and aqueducts (waterways) to deliver clean
ease were punishments from the gods. Religious water. They drained swamps and marshes to
rites and ceremonies were frequently used to reduce the incidence of malaria. They created
eliminate evil spirits and restore health. Explor- laws to keep streets clean and eliminate garbage.
4 CHAPTER 1
TABLE 1-1 History of Health Care in Ancient Times

HISTORICAL EVENTS OF HEALTH CARE IN ANCIENT TIMES
4000 BC–3000 BC Believed that illness and disease were caused by supernatural spirits and demons
Primitive Times Tribal witch doctors treated illness with ceremonies to drive out evil spirits
Herbs and plants used as medicines and some, such as morphine for pain and digitalis for the
heart, are still used today
Trepanation or trephining (boring a hole in the skull) was used to treat insanity, epilepsy, and
headache
Average life span was 20 years
3000 BC–300 BC Earliest people known to maintain accurate health records
Ancient Egyptians Called upon the gods to heal them when disease occurred
Physicians were priests who studied medicine and surgery in temple medical schools
Imhotep (2635–2595? BC) may have been the first physician
Believed the body was a system of channels for air, tears, blood, urine, sperm, and feces
If channels became “clogged,” bloodletting or leeches were used to “open” them
Used magic and medicinal plants to treat disease
Average life span was 20 to 30 years
1700 BC–220 AD Religious prohibitions against dissection resulted in inadequate knowledge of body structure
Ancient Chinese Carefully monitored the pulse to determine the condition of the body
Believed in the need to treat the whole body by curing the spirit and nourishing the body
Recorded a pharmacopoeia of medications based mainly on the use of herbs
Used acupuncture, or puncture of the skin by needles, to relieve pain and congestion
Also used moxibustion (a powdered substance was placed on the skin and then burned to cause
a blister) to treat disease
Began the search for medical reasons for illness
1200 BC–200 BC Began modern medical science by observing the human body and effects of disease
Ancient Greeks Biochemist Alcmaeon in 6th century BC identified the brain as the physiological site of the senses
Hippocrates (460–377 BC) called the Father of Medicine:
• Developed an organized method to observe the human body
• Recorded signs and symptoms of many diseases
• Created a high standard of ethics, the Oath of Hippocrates, used by physicians today
Aristotle (384–322 BC) dissected animals and is called the founder of comparative anatomy
Believed illness is a result of natural causes
Used therapies such as massage, art therapy, and herbal treatment that are still used today
Stressed diet and cleanliness as ways to prevent disease
753 BC–410 AD First to organize medical care by providing care for injured soldiers
Ancient Romans Early hospitals developed when physicians cared for ill people in rooms in their homes
Later hospitals were religious and charitable institutions housed in monasteries and convents
Began public health and sanitation systems:
• Created aqueducts to carry clean water to the cities
• Built sewers to carry waste materials away from the cities
• Used filtering systems in public baths to prevent disease
• Drained marshes to reduce the incidence of malaria
Claudius Galen (129–199? AD), a physician, established many medical beliefs:
• Body regulated by four fluids or humors: blood, phlegm, black bile, and yellow bile
• An imbalance in the humors resulted in illness
• Described symptoms of inflammation and studied infectious diseases
• Dissected animals and determined function of muscles, kidney, and bladder
Diet, exercise, and medications were used to treat disease
THE DARK AGES AND

MIDDLE AGES
Table 1-2 lists many of the historical events of the
Dark Ages and the Middle Ages. During the Dark
Ages, after the fall of the Roman empire, the study
of medicine stopped. Individuals again lived in
unsanitary conditions with little or no personal
hygiene. Epidemics of smallpox, dysentery, typhus,
and the plague were rampant. Monks and priests
stressed prayer to treat illness and disease.
The Middle Ages brought a renewed interest
in the medical practices of the Romans and
Image not available due to copyright restrictions Greeks. Monks obtained and translated the writ-
ings of the Greek and Roman physicians, and
recorded the knowledge in handwritten books.
Medical universities were created in the 9th cen-
tury to train physicians how to use this knowl-
edge to treat illness. Later, Arabs began requiring
that physicians pass examinations and obtain
licenses.
In the 1300s, a major epidemic of bubonic
plague killed almost 75 percent of the popula-
tion of Europe and Asia. Other diseases such as
smallpox, diphtheria, tuberculosis, typhoid, and
malaria killed many others. The average life span
of 20 to 35 years was often reduced even more
by the presence of these diseases. Many infants
died shortly after birth. Many children did not
live into adulthood. Today, most of these diseases
are almost nonexistent. They are prevented by
vaccines or treated by medications.
THE RENAISSANCE
Table 1-3 lists many of the historical events that
occurred between 1350 and 1650 AD, a period
The first hospitals were also established in ancient known as the Renaissance. This period often
Rome when physicians began caring for injured refers to the “rebirth of science of medicine.” The
soldiers or ill people in their homes. major source of new information about the
Although many changes occurred in health human body was a result of accepting and allow-
care during ancient times, treatment was still lim- ing human dissection. Doctors could now view
ited. The average person had poor personal body organs and see the connection between
hygiene, drank contaminated water, and had different systems in the body. Artists, such as
unsanitary living conditions. Diseases such as Michelangelo and Leonardo da Vinci, were able
typhoid, cholera, malaria, dysentery, leprosy, and to draw the body accurately. In addition, the
smallpox infected many individuals. Because the development of the printing press resulted in
causes of these diseases had not been discovered, the publication of medical books that were
the diseases were usually fatal. The average life used by students at medical universities. Knowl-
span was 20 to 35 years. Today, individuals who edge spread more rapidly. Physicians were more
die at this age are considered to be young people. educated.
6 CHAPTER 1
TABLE 1-2 History of Health Care in the Dark Ages and the Middle Ages
HISTORICAL EVENTS OF HEALTH CARE IN THE DARK AGES AND THE MIDDLE AGES
400–800 AD Emphasis was placed on saving the soul and the study of medicine was prohibited
Dark Ages Prayer and divine intervention were used to treat illness and disease
Monks and priests provided custodial care for sick people
Medications were mainly herbal mixtures
800–1400 AD Renewed interest in the medical practice of Greeks and Romans
Middle Ages Physicians began to obtain knowledge at medical universities in the 9th century
A pandemic (worldwide epidemic) of the bubonic plague (black death) killed three quarters of the
population of Europe and Asia
Major diseases were smallpox, diphtheria, tuberculosis, typhoid, the plague, and malaria
Arab physicians used their knowledge of chemistry to advance pharmacology
Rhazes (al-Razi), an Arab physician, became known as the Arab Hippocrates:
• Based diagnoses on observations of the signs and symptoms of disease
• Developed criteria for distinguishing between smallpox and measles in 910 AD
• Suggested blood was the cause of many infectious diseases
• Began the use of animal gut for suture material
Arabs began requiring that physicians pass examinations and obtain licenses
Avenzoar, a physician, described the parasite causing scabies in the 12th century
TABLE 1-3 History of Health Care in the Renaissance

HISTORICAL EVENTS OF HEALTH CARE IN THE RENAISSANCE
1350–1650 AD Rebirth of science of medicine

Renaissance Dissection of the body began to allow a better understanding of anatomy and physiology
Artists Michelangelo (1475–1564) and Leonardo da Vinci (1452–1519) used dissection to draw the
human body more realistically
First chairs (positions of authority) of medicine created at Oxford and Cambridge in England in 1440
Development of the printing press allowed knowledge to be spread to others
First anatomy book was published by Andreas Vesalius (1514–1564)
First book on dietetics written by Isaac Judaeus
Michael Servetus (1511–1553):
• Described the circulatory system in the lungs
• Explained how digestion is a source of heat for the body
Roger Bacon (1214?–1294):
• Promoted chemical remedies to treat disease
• Researched optics and refraction (bending of light rays)
TABLE 1-4 History of Health Care in the 16th, 17th, and 18th Centuries
HISTORICAL EVENTS OF HEALTH CARE IN THE 16TH, 17TH, AND 18TH CENTURIES
16th and 17th Causes of disease were still not known and many people died from infections and puerperal (child-
Centuries birth) fever
Ambroise Paré (1510–1590), a French Surgeon, known as the Father of Modern Surgery:
• Established use of ligatures to bind arteries and stop bleeding
• Eliminated use of boiling oil to cauterize wounds
• Improved treatment of fractures and promoted use of artificial limbs
Gabriel Fallopius (1523–1562):
• Identified the fallopian tubes in the female
• Described the tympanic membrane in the ear
William Harvey (1578–1657) described the circulation of blood to and from the heart in 1628
Anton van Leeuwenhoek (1632–1723) invented the microscope in 1666
First successful blood transfusion on animals performed in England in 1667
Bartolomeo Eustachio identified the eustachian tube leading from the ear to the throat
Scientific societies, such as the Royal Society of London, were established
Apothecaries (early pharmacists) made, prescribed, and sold medications
18th Century Gabriel Fahrenheit (1686–1736) created the first mercury thermometer in 1714
Joseph Priestley (1733–1804) discovered the element oxygen in 1774
John Hunter (1728–1793), an English surgeon:
• Established scientific surgical procedures
• Introduced tube feeding in 1778
Benjamin Franklin (1706–1790) invented bifocals for glasses
Dr. Jessee Bennet performed the first successful Cesarean section operation to deliver an infant in
1794
James Lind prescribed lime juice containing vitamin C to prevent scurvy in 1795
Edward Jenner (1749–1823) developed a vaccination for smallpox in 1796
The life span increased to an average age of A major development was the invention of
30 to 40 years during the Renaissance, but com- the microscope by Anton van Leeuwenhoek (fig-
mon infections still claimed many lives. At this ure 1-2). This allowed physicians to see organ-
point in time, the actual causes of disease were isms that are too small to be seen by the human
still a mystery. eye. Even though they were not aware of it at the
time, physicians were looking at many of the
THE 16TH, 17TH, AND pathogenic organisms (germs) that cause dis-
ease. The microscope continues to be a major
18TH CENTURIES diagnostic tool.
This period also saw the start of drug stores, or
Table 1-4 lists many of the historical events that pharmacies. Apothecaries (early pharmacists)
occurred during the 16th, 17th, and 18th centu- made, prescribed, and sold medications. Many of
ries. During this period, physicians gained an the medications were made from plants and herbs
increased knowledge of the human body. William similar to those used in ancient times. At the end
Harvey described the circulation of blood. Gabriel of the 18th century, Edward Jenner developed a
Fallopius described the tympanic membrane in vaccine to prevent smallpox, a deadly disease.
the ear and the fallopian tubes of a female. Bar- During this time, the average life span
tolomeo Eustachio identified the tube between increased to 40 to 50 years. However, the causes
the ear and throat. These discoveries allowed of many diseases were still unknown, and medi-
other physicians to see how the body functioned. cal care remained limited.
8 CHAPTER 1
Anton van Leeuwenhoek (1632–1723) is one of sev- René-Théophile-Hyacinthe Laënnec (1781–1826) was
eral individuals who are called the “Father of Microbiol- a French physician who is frequently called the “Father
ogy” because of his discovery of bacteria and other of Pulmonary Diseases.” In 1816, he invented the
microscopic organisms. He was born in Delft, Holland, stethoscope, which began as a piece of rolled paper
and worked as a tradesman and apprentice to a textile and evolved into a wooden tube that physicians
merchant. van Leeuwenhoek learned to grind lenses inserted into their ears.
and make simple microscopes to use while examining Laënnec used his stethoscope to listen to the various
the thread densities of materials. sounds made by the heart and lungs. For years he stud-
In 1668, he visited London and saw a copy of Robert ied chest sounds and correlated them with diseases
Hookes’s Micrographia, a book depicting Hookes’s own found on autopsy. In 1819, he published a book on his
observations with the microscope. This stimulated van findings, De l’auscultation mediate, also known as On
Leeuwenhoek’s interest and he began to build micro- Mediate Auscultation. Laënnec’s use of auscultation (lis-
scopes that magnified more than 200 times, with clearer tening to internal body sounds) and percussion (tapping
and brighter images than were available at the time. body parts to listen to sounds) formed the basis of the
Using the improved microscope, van Leeuwenhoek diagnostic techniques used in medicine today.
began to observe bees, bugs, water, and other similar Laënnec studied and diagnosed many medical con-
substances. He noticed tiny single-celled organisms that ditions such as bronchiectasis, melanoma, cirrhosis,
he called animalcules, now known as microorganisms. and tuberculosis. Cirrhosis of the liver is still called
When van Leeuwenhoek reported his observations to Laënnec’s cirrhosis because Laënnec was the first phy-
the Royal Society of London, he was met with skepti- sician to recognize this condition as a disease entity.
cism. However, other scientists researched his findings, Laënnec also conducted extensive studies on tubercu-
and eventually his ideas were proved and accepted. losis, but unfortunately he was not aware of the conta-
van Leeuwenhoek was the first individual to record giousness of the disease and contracted tuberculosis
microscopic observations on muscle fibers, blood ves- himself. He died at the age of 45 of tuberculosis, leaving
sels, and spermatozoa. He laid the foundations of plant a legacy of knowledge that is still used by physicians
anatomy and animal reproduction. He developed a today.
method for grinding powerful lenses and made more
than 400 different types of microscopes. Anton van FIGURE 1-3 René Laënnec (Courtesy of Parke-
Leeuwenhoek’s discoveries are the basis for microbiol- Davis and Company, copyright 1957)
ogy today.
FIGURE 1-2 Anton van Leeuwenhoek

allowed physicians to listen to internal body
sounds, which increased their knowledge of the
THE 19TH CENTURY human body. The original stethoscope, a rolled
piece of paper, quickly evolved into a wooden
Table 1-5 lists many of the historical events that tube that was inserted into the physician’s ear.
occurred during the 19th century, a period also Formal training for nurses began during this
known as the Industrial Revolution. Major progress century. After training at a program in Germany,
in medical science occurred because of the devel- Florence Nightingale established sanitary nurs-
opment of machines and ready access to books. ing care units for injured soldiers during the
Early in the century, René Laënnec invented Crimean War. She is known as the founder of
the stethoscope (figure 1-3). This invention modern nursing (figure 1-4).
TABLE 1-5 History of Health Care in the 19th Century

HISTORICAL EVENTS OF HEALTH CARE IN THE 19TH CENTURY
19th Century Royal College of Surgeons (medical school) founded in London in 1800
French barbers acted as surgeons by extracting teeth, using leeches for treatment, and giving enemas
First federal vaccination legislation enacted in 1813
First successful blood transfusion was performed on humans in 1818 by James Blundell
René Laënnec (1781–1826) invented the stethoscope in 1816
Dr. Philippe Pinel (1755–1826) began humane treatment for mental illness
Pandemic of cholera in 1832
Theodor Fliedner started one of the first training programs for nurses in Germany in 1836, which
provided Florence Nightingale with her formal training
In the 1840s, Ignaz Semmelweis (1818–1865) encouraged physicians to wash their hands with lime
after performing autopsies and before delivering babies to prevent puerperal (childbirth) fever, but the
idea was resisted by hospital and medical personnel
Dr. William Morton (1819–1868), an American dentist, began using ether as an anesthetic in 1846
Dr. James Simpson (1811–1870) began using chloroform as an anesthetic in 1847
American Medical Association was formed in Philadelphia in 1847
Elizabeth Blackwell (1821–1910) became the first female physician in the United States in 1849;
started the first Women’s Medical College in New York in 1868
American Pharmaceutical Association held its first convention in 1853
Florence Nightingale (1820–1910) was the founder of modern nursing:
• Established efficient and sanitary nursing units during Crimean War in 1854
• Opened Nightingale School and Home for Nurses at St. Thomas’ Hospital in London in 1860
• Began the professional education of nurses
Dorothea Dix (1802–1887) appointed Superintendent of Female Nurses of the Army in 1861
International Red Cross was founded in 1863
Joseph Lister (1827–1912) started using disinfectants and antiseptics during surgery to prevent infec-
tion in 1865
Elizabeth Garrett Anderson (1836–1917) became the first female physician in Britain in 1870 and the
first woman member of the British Medical Association in 1873
Paul Ehrlich (1854–1915), a German bacteriologist, developed methods of detecting and differentiating
between various diseases, developed the foundation for modern theories of immunity, and used
chemicals to eliminate microorganisms
Francis Clarke and M. G. Foster patented the first electrical hearing aid in 1880
Clara Barton (1821–1912) founded the American Red Cross in 1881
Robert Koch (1843–1910), another individual who is also called the “Father of Microbiology,” devel-
oped the culture plate method to identify pathogens and in 1882 isolated the bacteria that causes
tuberculosis
Louis Pasteur (1822–1895) contributed many discoveries to the practice of medicine including:
• Proving that microorganisms cause disease
• Pasteurizing milk to kill bacteria
• Creating a vaccine for rabies in 1885
Gregory Mendel (1822–1884) established principles of heredity and dominant/recessive patterns
Dimitri Ivanofski discovered viruses in 1892
Lillian Wald (1867–1940) established the Henry Street Settlement in New York City in 1893 (the start
of public health nursing)
Dr. Emile Roux of Paris developed a vaccine for diphtheria in 1894
Wilhelm Roentgen (1845–1923) discovered roentgenograms (X-rays) in 1895
Almroth Wright developed a vaccine for typhoid fever in 1897
Bayer introduced aspirin in powdered form in 1899
Bacteria causing gonorrhea and leprosy were discovered and identified
10 CHAPTER 1
Florence Nightingale (1820–1910) is known as the Louis Pasteur (1822–1895) was a French chemist and
founder of modern nursing. In 1854, Nightingale led 38 biologist. He is also called the “Father of Microbiological
nurses to serve in the Crimean War. During the war, Sciences and Immunology” because of his work with
the medical services of the British army were horrifying the microorganisms that cause disease. Pasteur devel-
and inadequate. Hundreds of soldiers died because of oped the germ theory and discovered the processes of
poor hygiene and unsanitary conditions. Nightingale pasteurization, vaccination, and fermentation. His germ
fought for the reform of the military hospitals and for theory proved that microorganisms cause most infec-
improved medical care. tious diseases. He proved that heat can be used to
Nightingale encouraged efficiency and cleanliness destroy harmful germs in perishable food, a process
in the hospitals. Her efforts decreased the death rate of now known as “pasteurization.” Pasteur also discovered
patients by two thirds. She used statistics to prove that that weaker microorganisms could be used to immunize
the number of deaths decreased with improved sani- against more poisonous forms of a microorganism. He
tary conditions. Because of her statistics, sanitation developed vaccines against anthrax, chicken cholera,
reforms occurred and medical practice improved. rabies, and swine erysipelas. Through his studies of fer-
One of Nightingale’s greatest accomplishments was mentation, he proved that each disease is caused by a
starting the Nightingale Training School for nurses at specific microscopic organism.
St. Thomas’ Hospital in London. Nurses attending her Pasteur’s principles for sanitation helped control the
school received a year’s training, which included lec- spread of disease and provided ideas on how to pre-
tures and practical ward work. Trained nurses were vent disease. These discoveries reformed surgery and
then sent to work in British hospitals and abroad. These obstetrics. Pasteur is responsible for saving the lives of
trained nurses also established other nursing schools millions of people through vaccination and pasteuriza-
by using Nightingale’s model. Nightingale published tion. His accomplishments are the foundation of bacte-
more than 200 books, pamphlets, and reports. Her riology, immunology, microbiology, molecular biology,
writings on hospital organization had a lasting effect in and virology in today’s health care.
England and throughout the world. Many of her princi- FIGURE 1-5 Louis Pasteur (Courtesy of Parke-
ples are still used in health care today.
Davis and Company, copyright 1957)
FIGURE 1-4 Florence Nightingale (Courtesy of
Parke-Davis, a division of Warner-Cambert the army. Clara Barton founded the American
Company) Red Cross (figure 1-6).
The average life span during this period
Infection control was another major develop- increased to 40 to 65 years. Treatment for disease
ment. Physicians began to associate the tiny was more specific after the causes for diseases
microorganisms seen in the microscope with dis- were identified. Many vaccines and medications
eases. Methods to stop the spread of these organ- were developed.
isms were developed by Theodor Fliedner, Joseph
Lister, and Louis Pasteur (figure 1-5).
Women became active participants in medi-
cal care. Elizabeth Blackwell was the first female
THE 20TH CENTURY
physician in the United States. Dorothea Dix was Table 1-6 lists many of the historical events that
appointed superintendent of female nurses in occurred during the 20th century. This period
Francis Crick and James Watson shared the Nobel

Clara Barton (1821–1912) is known as the founder of Prize in 1962 with Maurice Wilkins for discovering the
the American Red Cross. During the American Civil structure of deoxyribonucleic acid (DNA). Crick is a
War, she served as a volunteer to provide aid to biophysicist and chemist. Watson studied zoology.
wounded soldiers. She appealed to the public to pro- They met at the University of Cambridge and shared a
vide supplies and, after collecting the supplies, person- desire to solve the mystery of the structure of DNA.
ally delivered them to soldiers of both the North and Crick and Watson built a three-dimensional model
the South. of the molecules of DNA to assist them in discovering
In 1869, Barton went to Geneva, Switzerland, to the structure. In 1953, they discovered that the struc-
rest and improve her health. During her visit she ture of DNA is a double helix, similar to a gently twisted
learned about the Treaty of Geneva, which provided ladder. It consists of pairs of bases, including adenine
relief for sick and wounded soldiers. A dozen nations and thymine, and guanine and cytosine. The order in
had signed the treaty, but the United States had which these bases appear on the double helix deter-
refused. She also learned about the International Red mines the identity of a living organism. That is, DNA
Cross, which provided disaster relief during peacetime carries life’s hereditary information.
and war. Crick and Watson’s model of the DNA double helix
When Barton returned to the United States, she provided motivation for research in molecular genetics
campaigned for the Treaty of Geneva until it was rati- and biochemistry. Their work showed that understand-
fied. In 1881, the American Red Cross was formed. ing how a structure is arranged is critical to under-
Barton served as its first president. She represented standing how it functions. Crick and Watson’s discovery
the American Red Cross by traveling all over the United is the foundation for most of the genetic research that
States and the world to assist victims of natural disas- is being conducted today.
ters and war.
FIGURE 1-7A Francis Crick and James Watson
FIGURE 1-6 Clara Barton (Courtesy of the (Courtesy of the Salk Institute)
National Archives, photo no. 111-B-4 246, Brady
Collection)
(figures 1-7A and B). Their studies began the
showed the most rapid growth in health care. search for gene therapy to cure inherited dis-
Physicians were able to use new machines such eases. This research continues today.
as X-rays to view the body. Medicines, including Health care plans to help pay the costs of care
insulin for diabetes, antibiotics to fight infec- also started in the 20th century. At the same time,
tions, and vaccines to prevent diseases, were standards were created to make sure that every
developed. The causes for many diseases were individual had access to quality health care. This
identified. Physicians were now able to treat the remains a major concern of health care in the
cause of a disease to cure the patient. United States today.
A major development to understanding the The first open-heart surgery in the 1950s has
human body occurred in the 1950s when Francis progressed to the heart transplants that occur
Crick and James Watson described the structure today. Surgical techniques have provided cures
of DNA and how it carries genetic information for what were once fatal conditions. Infection
12 CHAPTER 1
Nucleus (1)
Cell membrane
Basic
cell DNA
molecule (3)
Gene (4)
Cytoplasm
Chromosomes (2)
FIGURE 1-7B The discovery of the structure of DNA and how it carries genetic (inherited) information was
the beginning of research on how to cure inherited diseases by gene therapy.
TABLE 1-6 History of Health Care in the 20th Century

20th Century Walter Reed demonstrated that mosquitoes carry yellow fever in 1900
Carl Landsteiner classified the ABO blood groups in 1901
Female Army Nurse Corps established as a permanent organization in 1901
Miller Reese of New York patented the battery-driven hearing aid in 1901
Dr. Harry Plotz developed a vaccine against typhoid in 1903
Dr. Elie Metchnikoff (1845–1916) identified how white blood cells protect against disease
Marie Curie (1867–1934) isolated radium in 1910
Sigmund Freud’s (1856–1939) studies formed the basis for psychology and psychiatry
Influenza (flu) pandemic killed more than 21 million people in 1918
Frederick Banting and Charles Best discovered and used insulin to treat diabetes in 1922
Health insurance plans and social reforms were developed in the 1920s
Mary Breckinridge (1881–1965) founded Frontier Nursing Service in 1925 to deliver health care to
rural Kentuckians
John Enders and Frederick Robbins developed methods to grow viruses in cultures in the 1930s
Sir Alexander Fleming (1881–1955) discovered penicillin in 1928
Buddy, a German shepherd, became the first guide dog for the blind in 1928
Dr. Robert Smith (Dr. Bob) and William Wilson founded Alcoholics Anonymous in 1935
President Franklin Roosevelt established the March of Dimes to fight poliomyelitis in 1937
Gerhard Domagk (1895–1964) developed sulfa drugs to fight infections
Dr. George Papanicolaou developed the Pap test to detect cervical cancer in females in 1941
The first kidney dialysis machine was developed in 1944
Jonas Salk (1914–1995) developed the polio vaccine using dead polio virus in 1952
Francis Crick and James Watson described the structure of DNA and how it carries genetic information
in 1953
(continues)
TABLE 1-6 History of Health Care in the 20th Century (Continued)

The first heart–lung machine was used for open-heart surgery in 1953
Conjoined (Siamese) twins were separated successfully for the first time in 1953
The first successful kidney transplant in humans was performed by Joseph Murray in 1954
Albert Sabin (1906–1993) developed an oral live-virus polio vaccine in the mid-1950s
Birth control pills approved by the U.S. Food and Drug Administration (FDA) in 1960
An arm severed at the shoulder was successfully reattached to body in 1962
The first liver transplant was performed by Thomas Starzl in 1963
The first lung transplant was performed by James Hardy in 1964
Medicare and Medicaid 1965 Amendment to Social Security Act marked the entry of the federal gov-
ernment into the health care arena as a major purchaser of health services
The first successful heart transplant was performed by Christian Barnard in 1967
The first hospice was founded in England in 1967
Hargobind Khorana synthesized a gene in 1970
Health Maintenance Organization Act of 1973 established standards for HMOs and provided an alterna-
tive to private health insurance
Physicians used amniocentesis to diagnose inherited diseases before birth in 1975
Computerized axial tomography (CAT) scan was developed in 1975
New Jersey Supreme Court ruled that parents of Karen Ann Quinlan, a comatose woman, had the
power to remove life support systems in 1975
The first “test tube” baby, Louise Brown, was born in England in 1978
Genetic engineering led to development of vaccines against hepatitis, herpes simplex, and chicken pox
in the 1980s
Acquired immune deficiency syndrome (AIDS) was identified as a disease in 1981
Dr. William DeVries implanted the first artificial heart, the Jarvik-7, in 1982
Cyclosporine, a drug to suppress the immune system after organ transplants, approved in 1983
The Human immunodeficiency virus (HIV) causing AIDS was identified in 1984
The Omnibus Budget Reconciliation Act (OBRA) of 1987 established regulations for the education and
certification of nursing assistants
The Omnibus Budget Reconciliation Act of 1989 created an agency for health care policy and research
to develop outcome measures of health care quality
The first gene therapy to treat disease occurred in 1990
President George H. Bush signed the Americans with Disabilities Act in 1990
The National Center for Complementary and Alternative Medicine (NCCAM) was established by the
National Institutes of Health (NIH) to research and establish standards of quality care in 1992
A vaccine for chicken pox was approved in 1995
The British government admitted that an outbreak of “mad cow” disease was linked to Creutzfeldt–
Jacob disease in humans in 1996
President Clinton signed the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to
protect patient privacy and to make it easier to obtain and keep health insurance
Identification of genes causing diseases increased rapidly in the 1990s
A sheep was cloned in 1997
The first successful larynx (voice box) transplant was performed in 1998
An international team of scientists sequenced the first human chromosome in 1999
control has helped decrease surgical infections periods combined. Today, computers are used in
that previously killed many patients. every aspect of health care. Their use will increase
The contribution of computer technology to even more in the 21st century.
medical science has helped medicine progress All of these developments have helped
faster in the 20th century than in all previous increase the average life span to 60 to 80 years. In
14 CHAPTER 1
age system. After the operation, both boys were able to

survive independently. This result was the first surgery to
separate occipital craniopagus twins, meaning they were
joined at the head near the occipital bone. In 1997, Dr. Car-
son was the lead surgeon in South Africa in another suc-
cessful operation to separate 11-month-old boys who were
vertical craniopagus twins, meaning they were joined at
the top of the head looking in opposite directions.
Dr. Carson continues to perform landmark surgeries
and conduct research for new techniques and procedures.
He has refined hemispherectomy, a revolutionary surgical
procedure performed on the brain to stop seizures that
are difficult to treat or cure. He works with craniofacial
(head or facial disfigurement) reconstructive surgery. Dr.
Carson has developed an important craniofacial program
that combines neurosurgery and plastic surgery for chil-
dren with congenital (at birth) deformities. He is also
known for his work in pediatric neurooncology (brain
tumors).
Dr. Carson is the author of three best-selling books:
Benjamin Carson, MD, has become famous for his land- Gifted Hands, the story of his life; Think Big, a story inspir-
mark surgeries to separate conjoined twins. Dr. Carson is ing others to use their intelligence; and The Big Picture, a
one of the most skilled and accomplished neurosurgeons close-up look at the life of a professional surgeon. Dr. Car-
today. son is also cofounder and president of the Carson Schol-
In 1987, he was the primary surgeon of a 70- ar’s Fund. This fund was established to recognize young
member surgical team that separated Siamese twins from people for superior academic performance and humani-
West Germany. The 7-month-old boys were joined at the tarian achievement.
back of the head, sharing the major cerebral blood drain-
FIGURE 1-8 Benjamin Carson, MD (Courtesy of Carson Scholar’s Fund)

fact, it is not unusual to see people live to be 100. At the same time, however, scientists now
With current pioneers such as Ben Carson (figure have computers and rapid methods of communi-
1-8), as well as many other medical scientists and cation to share new knowledge. Organizations
physicians, there is no limit to what future health such as the World Health Organization (WHO), an
care will bring. international agency sponsored by the United
Nations, are constantly monitoring health prob-
lems throughout the world and taking steps to
THE 21ST CENTURY prevent pandemics. Health care has become a
global concern and countries are working together
The potential for major advances in health care to promote good health in all individuals.
in the 21st century is unlimited. Early in the cen- Table 1-7 lists some of the events that have
tury, the completion of the Human Genome Proj- occurred so far in the 21st century and some pos-
ect by the U.S. Department of Energy and the sible advances that might occur soon. The poten-
National Institutes of Health (NIH) provided the tial for the future of health care has unlimited
basis for much of the current research on genet- possibilities.
ics. Research with embryonic stem cells and
development of cloned cells could lead to treat-
ments that will cure many diseases.
Some major threats to health care exist in this
century. Bioterrorism, the use of microorganisms 1:2 INFORMATION
or biologic agents as weapons to infect humans,
is a real and present threat. New viruses, such as
Trends in Health Care
the bird flu virus, could mutate and cause disease Health care has seen many changes during the
in humans. Pandemics, or worldwide epidemics, past several decades, and many additional
could occur quickly in our global society because changes will occur in the years to come. An aware-
people can travel easily from one country to ness of such changes and trends is important for
another. any health care worker.
TABLE 1-7 History of Health Care in the 21st Century

HISTORICAL EVENTS OF HEALTH CARE IN THE 21ST CENTURY
21st Century Adult stem cells were used in the treatment of disease early in the 2000s
The U.S. Food and Drug Administration (FDA) approved the use of the abortion pill RU-486 in 2000
President George W. Bush approved federal funding for research using only existing lines of em-
bryonic stem cells in 2001
Advanced Cell Technology announced it cloned a human embryo in 2001 but the embryo did not
survive
The first totally implantable artificial heart was placed in a patient in Louisville, Kentucky, in 2001
Smallpox vaccinations were given to military personnel and first responders to limit the effects of a
potential bioterrorist attack in 2002
The Netherlands became the first country in the world to legalize euthanasia in 2002
The Human Genome Project to identify all of the approximately 20,000 to 25,000 genes in human
DNA was completed in 2003
The Standards for Privacy of Individually Identifiable Health Information, required under the Health
Insurance Portability and Accountability Act (HIPAA) of 1996, went into effect in 2003
The Medicare Prescription Drug Improvement and Modernization Act was passed in 2003
The virus that causes severe acute respiratory syndrome (SARS) was identified in 2003 as a new
coronavirus, never seen in humans previously
National Institutes of Health (NIH) researchers discover that primary teeth can be a source of stem
cells in 2003
First face transplant was performed in France in 2005 on a woman whose lower face was destroyed
by a dog attack
Stem cell researchers at the University of Minnesota coaxed embryonic stem cells to produce
cancer-killing cells in 2005
The National Cancer Institute (NCI) and the National Human Genome Research Institute started a
project to map genes associated with cancer so mutations that occur with specific cancers can be
identified in 2006
The FDA approved the use of the AbioCor totally implantable artificial heart in 2006
The first inhalable insulin product, Exubera, was approved by the FDA in 2006
Researchers propose a new method to generate embryonic stem cells from a blastocyst without
destroying embryos in 2006
Gardasil, a vaccine to prevent cervical cancer, was approved by the FDA in 2006
Zostavax, a vaccine to prevent herpes zoster (shingles), was approved by the FDA in 2006
Potential for the Cures for AIDS, cancer, and heart disease are found
21st Century Genetic manipulation to prevent inherited diseases is a common practice
Development of methods to slow the aging process or stop aging are created
Nerves in the brain and spinal cord are regenerated to eliminate paralysis
Transplants of every organ in the body, including the brain, are possible
Antibiotics are developed that do not allow pathogens to develop resistance
Average life span is increased to 90 to 100 years and beyond
COST CONTAINMENT ♦ Technological advances: highly technical pro-

cedures such as heart, lung, liver, or kidney
Cost containment, a term heard frequently in transplants can cost hundreds of thousands of
health care circles, means trying to control the dollars. Even so, many of these procedures are
rising cost of health care and achieving the maxi- performed daily throughout the United States.
mum benefit for every dollar spent. Some reasons Artificial hearts are another new technology
for high health care costs include: being used. Computers that can be used to
16 CHAPTER 1
examine internal body parts are valuable diag- example, a large medical laboratory with
nostic tools, but these devices can cost mil- expensive computerized equipment perform-
lions of dollars. Advanced technology does ing thousands of tests per day can provide
allow people to survive illnesses that used to quality service at a much lower price than
be fatal, but these individuals may require smaller laboratories with less expensive equip-
expensive and lifelong care. ment capable of performing only a limited
♦ The aging population: older individuals use numbers of tests per day.
more pharmaceutical products (medications), ♦ Outpatient services: patients receive care
have more chronic diseases, and often need without being admitted to hospitals or other
frequent health care services. care facilities. Hospital care is expensive.
♦ Health-related lawsuits: lawsuits force health Reducing the length of hospital stays or
care providers to obtain expensive malprac- decreasing the need for hospital admissions
tice insurance, order diagnostic tests even lowers the cost of health care. For example,
though they might not be necessary, and make patients who had open-heart surgery used to
every effort to avoid lawsuits by practicing spend several weeks in a hospital. Today, the
defensive health care. average length of stay is 5 to 7 days. Less
expensive home care or transfer to a skilled-
Because these expenses must be paid, a major
care facility can be used for individuals who
concern is that health care costs could rise to lev-
require additional assistance. Surgery, radio-
els that could prohibit providing services to all
graphs, diagnostic tests, and many other pro-
individuals. However, everyone should have
cedures that once required admission to a
equal access to care regardless of their ability to
hospital are now done on an outpatient basis.
pay. Because of this, all aspects of health care are
directed toward cost containment. Although ♦ Mass or bulk purchasing: buying equipment
there is no firm answer to controlling health costs, and supplies in larger quantities at reduced
most agencies that deliver health care are trying prices. This can be done by combining the
to provide quality care at the lowest possible purchases of different departments in a single
price. Some methods of cost containment that agency, or by combining the purchases of sev-
are used include: eral different agencies. A major health care
system purchasing medical supplies for hun-
♦ Diagnostic related groups (DRGs): one dreds or thousands of health care agencies
way Congress is trying to control costs for gov- can obtain much lower prices than an indi-
ernment insurance plans such as Medicare and vidual agency. Computerized inventory can
Medicaid. Under this plan, patients with cer- be used to determine when supplies are
tain diagnoses who are admitted to hospitals needed and to prevent overstocks and waste.
are classified in one payment group. A limit is
placed on the cost of care, and the agency pro- ♦ Early intervention and preventive services: pro-
viding care receives this set amount. This viding care before acute or chronic disease
encourages the agency to make every effort to occurs. Preventing illness is always more cost-
provide care within the expense limit allowed. effective than treating illness. Methods used
If the cost of care is less than the amount paid, to prevent illness include patient education,
the agency keeps the extra money. If the cost of immunizations, regular physical examina-
care is more than the amount paid, the agency tions to detect problems early, incentives for
must accept the loss. individuals to participate in preventive activi-
ties, and easy access for all individuals to pre-
♦ Combination of services: done to eliminate
ventive health care services. Studies have
duplication of services. Clinics, laboratories
shown that individuals with limited access to
shared by different agencies, health mainte-
health services and restricted finances use
nance organizations (HMOs), preferred pro-
expensive emergency rooms and acute care
vider organizations (PPOs), and other similar
facilities much more frequently. Providing
agencies all represent attempts to control the
early intervention and care to these individu-
rising cost of health care. When health care
als is much more cost-efficient.
agencies join together or share specific ser-
vices, care can be provided to a larger number ♦ Energy conservation: monitoring the use of
of people at a decreased cost per person. For energy to control costs and conserve resources.
Major expenses for every health care industry/ respiratory therapy, social services, nutritional
agency are electricity, water, and/or gas. Most and food services, and other types of care can be
large health care facilities perform energy provided in the home environment.
audits to determine how resources are being
used and to calculate ways to conserve energy.
Methods that can be used for energy conserva- GERIATRIC CARE
tion include designing and building new
energy-efficient facilities; constantly monitor- Geriatric care, or care for the elderly, is
ing and maintaining heating/cooling systems; another field that will continue to experience
using insulation and thermopane windows to rapid growth in the future (figure 1-9). This is
prevent hot/cool air loss; repairing plumbing caused in part by the large number of individuals
fixtures immediately to stop water loss; replac- who are experiencing longer life spans because of
ing energy-consuming lightbulbs with fluores- advances in health care. Many people now enjoy
cent or energy-efficient bulbs; installing life spans of 80 years or more. Years ago, very few
infrared sensors to turn water faucets on and people lived to be 100 years old. This is becoming
off; and using alternative forms of energy such more and more common. Also, the “baby boom”
as solar power. Recycling is also a form of generation—the large number of people born
energy conservation, and most health care after World War II—is now reaching the geriatric
facilities recycle many different materials. age classification. Projections from the U.S. Cen-
sus Bureau indicate that the rate of population
The preceding are just a few examples of cost growth during the next 50 years will be slower for
containment. Many other methods will undoubt- all age groups, but the number of people in older
edly be applied in the years ahead. It is important age groups will continue to grow more than twice
to note that the quality of health care should not as rapidly as the total population. Many different
be lowered simply to control costs. To prevent this facilities will be involved in providing care and
from happening, the Agency for Health Care Pol- resources for this age group. Adult day care cen-
icy and Research (AHCPR) researches the quality ters, retirement communities, assisted/indepen-
of health care delivery and identifies the standards dent living facilities, long-term care facilities, and
of treatment that should be provided. In addition, other organizations will all see increased demand
every health care worker must make every effort for the services they provide.
to provide quality care while doing everything
possible to avoid waste and keep expenditures
down. Health care consumers must assume more
responsibility for their own care, become better
informed of all options for health care services,
and follow preventive measures to avoid or limit
illness and disease. Everyone working together
can help control the rising cost of health care.
HOME HEALTH CARE

Home health care is a rapidly growing
field. Diagnostic related groups and shorter
hospital stays have created a need for providing
care in the home. Years ago, home care was the
usual method of treatment. Doctors made house
calls, private duty nurses cared for patients in the
patients’ homes, babies were delivered at home,
and patients died at home. Current trends show a
return to some of these practices. Home care is
also another form of cost containment because it
is usually less expensive to provide this type of
care. All aspects of health care can be involved. FIGURE 1-9 Geriatric care is a field that will
Nursing care, physical and occupational therapy, continue to experience rapid growth.
18 CHAPTER 1
OBRA the Omnibus Budget Reconcilia- As consumers become computer literate,

tion Act (OBRA) of 1987 has led to the more health care services will be provided elec-
development of many regulations regarding long- tronically. Telemedicine machines, operating over
term care and home health care. This act requires telephone lines, are “user-friendly,” compact, and
states to establish training and competency eval- less expensive than when they were developed.
uation programs for nursing and geriatric assis- They are already allowing individuals with chronic
tants. Each assistant working in a long-term care illnesses or disabilities to receive care in the com-
facility or home health care is now required under fort of their homes. This decreases the need for
federal law to complete a mandatory, state- trips to medical care facilities. Patients can test
approved training program and pass a written blood sugar levels, oxygen levels, blood pressure
and/or competency examination to obtain certi- measurements, and other vital signs, and send
fication or registration. OBRA also requires con- the results to a physician/nurse; monitor pace-
tinuing education, periodic evaluation of makers; use online courses to learn how to man-
performance, and retraining and/or testing if a age their condition; schedule an “appointment”
nursing assistant does not work in a health care to talk with a health care provider “face to face”
facility for more than 2 years. Each state then through video monitors; receive electronic
maintains a registry of qualified individuals. reminders to take medications or perform diag-
The minimum skills required are specified in nostic tests; and receive answers to specific health
the Nurse Aide Competency Evaluation Program questions. In rural areas, where specialty care is
(NACEP) developed by the National Council of State often limited, telemedicine can provide a patient
Boards of Nursing. Programs that prepare nursing with access to specialists thousands of miles away.
and geriatric assistants use NACEP as a guideline to Telemedicine will become an important way of
ensure that the minimum requirements of OBRA delivering health care in future years.
are met. Many programs expand these require-
ments. OBRA also requires compliance with
patients’/residents’ rights, and forces states to
establish guidelines to ensure that such rights are
WELLNESS
observed and enforced. These regulations serve to Wellness, or the state of being in optimum
ensure certain standards of care. As the need for health with a balanced relationship between
geriatric care increases, additional regulations may physical, mental, and social health, is another
be created. It is important that every health care major trend in health care. People are more aware
worker be informed about all OBRA regulations to of the need to maintain health and prevent disease
comply with these regulations. because disease prevention improves the quality
of life and saves costs. More individuals are recog-
nizing the importance of exercise, good nutrition,
TELEMEDICINE weight control, and healthy living habits (figure
1-10). This has led to the establishment of well-
Telemedicine involves the use of video, audio, ness centers, weight-control facilities, health food
and computer systems to provide medical and/ stores, nutrition services, stress reduction coun-
or health care services. New technology now seling, and habit cessation management.
allows interactive services between health care Wellness is determined by the lifestyle choices
providers even though they are in different loca- made by an individual and involves many factors.
tions. For example, emergency medical techni- Some of the factors and ways to promote well-
cians (EMTs), at the scene of an accident or ness include:
illness, can use technology to transmit medical
data such as an electrocardiogram to an emer- ♦ Physical wellness: promoted by a well-bal-
gency department physician. The physician can anced diet; regular exercise; routine physical
then monitor the data and direct the care of the examinations and immunizations; regular
patient. Surgeons using a computer can guide a dental and vision examinations; and avoid-
remote-controlled arm (robotic) to perform surance of alcohol, tobacco, caffeine, drugs, envi-
gery on a patient many miles away. In other ronmental contaminants, and risky sexual
instances, a surgeon can direct the work of behavior
another surgeon by watching the procedure on ♦ Emotional wellness: promoted by understand-
video beamed by a satellite system. ing personal feelings and expressing them
toration. It is based on the body’s natural healing

powers, the various ways different tissues and
systems in the body influence each other, and the
effect of the external environment. It is essential
to remember that the patient is responsible for
choosing his or her own care. Health care workers
must respect the patient’s choices and provide
care that promotes the well-being of the whole
person.
COMPLEMENTARY AND
ALTERNATIVE METHODS
OF HEALTH CARE
The most common health care system in the
United States is the biomedical or “Western” sys-
tem. It is based on evaluating the physical signs
FIGURE 1-10 Individuals are recognizing the and symptoms of a patient, determining the cause
importance of exercise and healthy living habits.
of disease, and treating the cause. A major trend,
(Courtesy of Photodisc)
however, is an increase in the use of complemen-
tary or alternative (CAM) health care therapies.
appropriately, accepting one’s limitations, Complementary therapies are methods of
adjusting to change, coping with stress, enjoy- treatment that are used in conjunction with con-
ing life, and maintaining an optimistic out- ventional medical therapies. Alternative thera-
look pies can be defined as methods of treatment that
♦ Social wellness: promoted by showing con- are used in place of biomedical therapies. Even
cern, fairness, affection, tolerance, and respect though the two terms are different, the term alter-
for others; communicating and interacting native is usually applied whether or not the ther-
well with others; sharing ideas and thoughts; apy is used in place of, or in conjunction with,
and practicing honesty and loyalty conventional medical therapies.
♦ Mental and intellectual wellness: promoted by Many health care facilities now offer inte-
being creative, logical, curious, and open- grative (integrated) health care, which uses
minded; using common sense; obtaining con- both mainstream medical treatments and CAM
tinual learning; questioning and evaluating therapies to treat a patient. For example, chronic
information and situations; learning from life pain is treated with both medications and CAM
experiences; and using flexibility and creativ- therapies that encourage stress reduction and
ity to solve problems relaxation. Integrative health care is based on the
principle that individuals have the ability to bring
♦ Spiritual wellness: promoted by using values, greater wellness and healing into their own lives
ethics, and morals to find meaning, direction, and that the mind affects the healing process. In
and purpose to life; often includes believing in addition, integrative care recognizes that each
a higher authority and observing religious person is unique and may require different medi-
practices cal treatments and a variety of CAM therapies.
The trend toward wellness has led to holistic For this reason, an integrative treatment plan
health care, or care that promotes physical, must be individualized to meet the patient’s own
emotional, social, intellectual, and spiritual well- special needs and circumstances.
being by treating the whole body, mind, and The interest in holistic health care has
spirit. Each patient is recognized as a unique per- increased the use of CAM therapies. Common
son with different needs. Holistic health care uses threads in these therapies are that they consider
many methods of diagnosis and treatment in the whole individual and recognize that the
addition to traditional Western medical practice. health of each part has an effect on the person’s
Treatment is directed toward protection and res- total health status; that each person has a life
20 CHAPTER 1
force or special type of energy that can be used in

the healing process; and that skilled practitio-
ners, rituals, and specialized practices are a part
of the therapy. Many of these therapies are based
on cultural values and beliefs. A few examples of
CAM practitioners include:
♦ Ayurvedic practitioners: use an ancient phi-
losophy, ayurveda, developed in India to
determine a person’s predominant dosha
(body type) and prescribe diet, herbal treat-
ment, exercise, yoga, massage, minerals, and
living practices to restore and maintain har-
mony in the body
♦ Chinese medicine practitioners: use an ancient
holistic-based healing practice based on the
belief that a life energy (Chi) flows through
every living person in an invisible system of
meridians (pathways) to link the organs
together and connect them to the external
environment or universe; use acupuncture
(figure 1-11), acupressure, tai chi, and herbal
remedies to maintain the proper flow of energy
and promote health
FIGURE 1-11 Acupuncture therapists insert very
♦ Chiropractors: believe that the brain sends thin needles into specific points along the meridians
vital energy to all body parts through nerves in (pathways) in the body to stimulate and balance the
the spinal cord; when there is a misalignment flow of energy.
of the vertebrae (bones), pressure is placed on
spinal nerves that results in disease and pain;
use spinal manipulation, massage, and exer-
cise to adjust the position of the vertebrae and expensive than other traditional treatments.
restore the flow of energy Many insurance programs now cover a wide vari-
ety of CAM therapies.
♦ Homeopaths: believe in the ability of the body Because of the increased use of CAM thera-
to heal itself through the actions of the immune pies, the federal government established
system; use minute diluted doses of drugs the National Center for Complementary and
made from plant, animal, and mineral sub- Alternative Medicine (NCCAM) at the National
stances to cause symptoms similar to the dis- Institutes of Health in 1992. Its purpose is to
ease and activate the immune system research the various therapies and determine
♦ Hypnotists: help an individual obtain a trance- standards of quality care. In addition, many states
like state with the belief that the person will be have passed laws to govern the use of various
receptive to verbal suggestions and able to therapies. Some states have established stan-
make a desired behavior change dards for some therapies, forbidden the use of
♦ Naturopaths: use only natural therapies such others, labeled specific therapies experimental,
as fasting, special diets, lifestyle changes, and and require a license or certain educational
supportive approaches to promote healing; requirements before a practitioner can adminis-
avoid the use of surgery or medicinal agents to ter a particular therapy. It is essential for health
treat disease care workers to learn the legal requirements of
their states regarding the different CAM thera-
Many different therapies are used in CAM pies. Health care workers must also remember
medicine. Some of these therapies are discussed that patients have the right to choose their
in Table 1-8. Most of the therapies are noninva- own type of care. A nonjudgmental attitude is
sive and holistic. In many instances, they are less essential.
TABLE 1-8 Complementary and Alternative Therapies

THERAPY BASIC DESCRIPTION
Acupressure Pressure is applied with fingers, palms, thumbs, or elbows to specific pressure points of the
(Shiatsu) body to stimulate and regulate the flow of energy; based on the belief that Chi (life energy)
flows through meridians (pathways) in the body, and illness and pain occur when the flow is
blocked; used to treat muscular–joint pain, depression, digestive problems, and respiratory
disorders; Shiatsu is the Japanese form of acupressure
Acupuncture Ancient Chinese therapy that involves the insertion of very thin needles into specific points
along the meridians (pathways) in the body to stimulate and balance the flow of energy; at
times, heat (moxibustion) or electrical stimulation is applied to the needles; based on the belief
that Chi (life energy) flows through the meridians, and illness and pain occur when the flow is
blocked; used to relieve pain, especially headache and back pain, reduce stress-related
illnesses, and treat drug dependency and obesity
Antioxidants Nutritional therapy that encourages the use of substances called antioxidants to prevent or
(Free Radicals) inhibit oxidation (chemical process in which a substance is joined to oxygen) and neutralize
free radicals (molecules that can damage body cells by altering the genetic code); examples of
antioxidants are vitamins A, C, and E, and selenium; may prevent heart disease, cataracts, and
some types of cancer
Aromatherapy Therapeutic use of selected fragrances (concentrated essences or essential oils that have been
extracted from roots, bark, plants, and/or flowers) to alter mood and restore the body, mind,
and spirit; fragrances may be diluted in oils for massages or placed in warm water or candles
for inhalation; used to relieve tense muscles and tension headaches or backaches, lower blood
pressure, and cause a stimulating, uplifting, relaxing, or soothing effect
Biofeedback Relaxation therapy that uses monitoring devices to provide a patient with information about
his/her reaction to stress by showing the effect of stress on heart rate, respirations, blood
pressure, muscle tension, and skin temperature; patient is then taught relaxation methods to
gain “mind” or voluntary control over the physical responses; used to treat hypertension (high
blood pressure), migraine headaches, and stress-related illnesses, and to enhance relaxation
Healing Touch Ancient Japanese/Tibetan healing art based on the idea that disease causes an imbalance in
(Reiki) the body’s energy field; begins with centering (inward focus of total serenity) before gentle
hand pressure is applied to the body’s chakras (energy centers) to harness and balance the life
energy force, help clear blockages, and stimulate healing; at times, hands are positioned
slightly above the energy centers; used to promote relaxation, reduce pain, and promote
wound healing
Herbal or Botanical Herbal medicine treatments that have been used in almost all cultures since primitive times;
Medicine based on the belief that herbs and plant extracts, from roots, stems, seeds, flowers, and
leaves, contain compounds that alter blood chemistry, remove impurities, strengthen the
immune system, and protect against disease
Homeopathy Treatment based on using very minute, dilute doses of drugs made from natural substances
to produce symptoms of the disease being treated; based on the belief that these substances
stimulate the immune system to remove toxins and heal the body; very controversial form of
treatment
Hydrotherapy Type of treatment that uses water in any form, internally and externally, for healing purposes;
common external examples include water aerobics and exercises, massage in or under water,
soaking in hot springs or tubs, and steam vapors; a common internal example is a diet that
encourages drinking large amounts of water to help cleanse the body and stimulate the
digestive tract
(continues)
22 CHAPTER 1
TABLE 1-8 Complementary and Alternative Therapies (Continued)

Hypnotherapy Technique used to induce a trancelike state so a person is more receptive to suggestion;
(Hypnosis) enhances a person’s ability to form images; used to encourage desired behavior changes such
as helping people lose weight, stop smoking, reduce stress, and/or relieve pain
Imagery Technique of using imagination and as many senses as possible to visualize a pleasant and
soothing image; used to decrease tension, anxiety, and adverse effects of chemotherapy
Ionization Special machines called air ionizers are used to produce negatively charged air particles or
Therapy ions; used to treat common respiratory disorders
Macrobiotic Diet Macrobiotic (meaning “long life”) is a nutrition therapy based on the Taoist concept of the bal-
ance between yin (cold, death, and darkness) and yang (heat, life, and light) and the belief that
different foods represent yin (sweet foods) and yang (meat and eggs); diet encourages
balanced foods such as brown rice, whole grains, nuts, vegetables, fruits, and fish; discour-
ages overindulgence of yin or yang foods; processed and treated foods, red meat, sugar, dairy
products, eggs, and caffeine should be avoided; similar to the American Dietary Association’s
low-fat, low-cholesterol, and high-fiber diet
Meditation Therapy that teaches breathing and muscle relaxation techniques to quiet the mind by focusing
attention on obtaining a sense of oneness within oneself; used to reduce stress and pain, slow
heart rate, lower blood pressure, and stimulate relaxation
Pet Therapy Therapy that uses pets, such as dogs, cats, and birds, to enhance health and stimulate an
interest in life; helps individuals overcome physical limitations, decrease depression, increase
self-esteem, socialize, and lower stress levels and blood pressure
Phytochemicals Nutritional therapy that recommends foods containing phytochemicals (nonnutritive plant
chemicals that store nutrients and provide aroma and color in plants) with the belief that the
chemicals help prevent disease; found mainly in a wide variety of fruits and vegetables, so
these are recommended for daily consumption; used to prevent heart disease, stroke, cancer,
and cataracts
Play Therapy Therapy that uses toys to allow children to learn about situations, share experiences, and express
their emotions; important aspect of psychotherapy for children with limited language ability
Positive Thought Therapy that involves developing self-awareness, self-esteem, and love for oneself to allow the
body to heal itself and eliminate disease; based on the belief that disease is a negative process
that can be reversed by an individual’s mental processes
Reflexology Ancient healing art based on the concept that the body is divided into ten equal zones that run
from the head to the toes; illness or disease of a body part causes deposits of calcium or acids
in the corresponding part of the foot; therapy involves applying pressure on specific points on
the foot so energy movement is directed toward the affected body part; used to promote
healing and relaxation, reduce stress, improve circulation, and treat asthma, sinus infections,
irritable bowel syndrome, kidney stones, and constipation
Spiritual Therapies Therapies based on the belief that a state of wholeness or health depends not only on physical
health, but the spiritual aspects of an individual; uses prayer, meditation, self-evaluation, and
spiritual guidance to allow an individual to use the powers within to increase the sense of well-
being and promote healing
Tai Chi Therapies based on the ancient theory that health is harmony with nature and the universe and a
balanced state of yin (cold) and yang (heat); uses a series of sequential, slow, graceful, and
precise body movements combined with breathing techniques to improve energy flow (Chi)
within the body; improves stamina, balance, and coordination and leads to a sense of well-
being; used to treat digestive disorders, stress, depression, and arthritis
TABLE 1-8 Complementary and Alternative Therapies (Continued)

Therapeutic Treatment that uses kneeling, gliding, friction, tapping, and vibration motions by the hands to
(Swedish) Massage increase circulation of the blood and lymph, relieve musculoskeletal stiffness, pain, and
spasm, increase range-of-motion, and induce relaxation
Therapeutic Touch Therapy based on an ancient healing practice with the belief that illness is an imbalance in an
individual’s energy field; the practitioner assesses alterations or changes in a patient’s energy
fields, places his/her hands on or slightly above the patient’s body, and balances the energy
flow to stimulate self-healing; used to encourage relaxation, stimulate wound healing, increase
the energy level, and decrease anxiety
Yoga Hindu discipline that uses concentration, specific positions, and ancient ritual movements to
maintain the balance and flow of life energy; encourages the use of both the body and mind to
achieve a state of perfect spiritual insight and tranquility; used to increase spiritual enlighten-
ment and well-being, develop an awareness of the body to improve coordination, relieve stress
and anxiety, and increase muscle tone
NATIONAL HEALTH affects a high proportion of the population. A

major concern today is that worldwide pandem-
CARE PLAN ics will become more and more frequent. Because
society is global and individuals can travel readily
The high cost of health care and large number of throughout the world, disease can spread much
uninsured individuals have created a demand for more rapidly from individual to individual.
a national health care plan. Many different types The World Health Organization (WHO) is
of plans have been proposed. One plan involves concerned about influenza pandemics occurring
nationalized medicine, where the federal govern- in the near future. Throughout history, influenza
ment would pay for all health services and levy pandemics have killed large numbers of people.
taxes to pay for those services. Another plan For example, the 1918 Spanish flu pandemic
involves the creation of health care cooperatives, killed approximately 2.6 percent of individuals
which would allow consumers to purchase health who contracted it, or about 40 million people.
care at lower costs. A third plan is based on man- Recently, researchers identified the virus that
aged care and requires employers to provide cov- caused this epidemic as an avian (bird) flu virus
erage and the federal government to subsidize that jumped directly to humans. This caused a
insurance for the poor. Still another plan would major alarm throughout the world because of the
allow each state to establish its own health care avian flu viruses, called H5N1 viruses, which are
plan paid for by employers, individuals, and/or present in countries in Asia and some other coun-
government subsidies. tries. These viruses pass readily from birds to
The main goal in health care reform is to birds and have devastated bird flocks in more
ensure that all Americans can get health coverage. than 11 countries. The infection has appeared in
Related problems include the cost of creating such humans, but most cases have resulted from con-
a system, the fact that those with insurance may tact with infected poultry or contaminated sur-
pay more to cover uninsured individuals, the lack faces. The spread from one person to another has
of freedom in choosing health care providers, and been reported only rarely. However, because the
the regulations that will have to be created to death rate for this bird flu in humans is between
establish a national health care system. 50 and 60 percent, a major concern is that the
H5N1 viruses will mutate and begin to spread
from birds to humans more readily. Even if the
PANDEMIC H5N1 viruses do not mutate and spread to
humans, WHO is still concerned about many
A pandemic exists when the outbreak of a dis- other viruses. Examples include the hantavirus
ease occurs over a wide geographic area and spread by rodents, severe acute respiratory syn-
24 CHAPTER 1
drome (SARS), monkeypox, and filoviruses such for immediate use, and more research must
as the Ebola virus and the Marburg virus that be done to develop and produce effective anti-
cause hemorrhagic fever. Because viruses are viral drugs
prone to mutation and exchanging genetic infor-
mation, the creation of a new lethal virus can ♦ Development of protective public health mea-
occur at any time. WHO estimates that 2 to 7 mil- sures: influenza must be diagnosed rapidly
lion people worldwide could die from infections and accurately, strict infection control meth-
by this type of virus. Other estimates are that tens ods must be implemented to limit the spread
of millions of people could die. of the virus, first responders and health care
Many governments are creating pandemic personnel must be immunized so they will be
influenza plans to protect their populations. able to care for infected individuals, and quar-
Components of most plans include the following: antine measures must be used if necessary to
control the spread of the disease
♦ Education: information about the pandemic
and ways to avoid its spread must be given to ♦ International cooperation: countries must be
the entire population willing to work with each other to create an
international plan that will limit the spread of
♦ Vaccine production: more research must be
lethal viruses and decrease the severity of a
directed toward producing effective vaccines
pandemic
in larger quantities and in a shorter period of
time In the near future, much effort will be directed
♦ Antiviral drugs: drugs that are currently avail- toward identifying and limiting the effect of any
able must be stockpiled so they will be ready organism that could lead to a pandemic. Health

The Food and Drug Administration regulating maggots and leeches as medical devices?
Throughout the history of health care, maggots and leeches have been used to treat
infection and encourage blood flow. Maggots clean festering, gangrenous wounds that fail
to heal. They eat the dead tissue and discharges to clean the wound and promote the growth
of new tissue. Leeches drain excess blood from tissue and encourage new circulation.
Microsurgeons, doctors who specialize in reattaching fingers, hands, and other body
appendages, have come to rely on the assistance of leeches. When microsurgeons reattach
or transplant a body part, they can usually connect arteries that bring blood to the append-
age. They find it more difficult to attach veins, which carry blood away from the appendage,
because veins are smaller and are fragile. Without a good venous supply, blood tends to col-
lect in the new attachment, clot, and in some cases, kill the tissue. To allow time for the body
to create its own veins to the new appendage, doctors apply leeches. The leeches naturally
inject the area with a chemical that includes an anticoagulant (a substance that prevents
clotting), an anesthetic, an antibiotic, and a vasodilator (a substance that dilates or enlarges
blood vessels). This chemical encourages the blood to flow quickly. The leeches drain this
blood to reduce pressure and allow veins to form.
Even though many individuals are squeamish about the use of maggots and leeches,
they have proved to be an effective method of treatment for chronic infections and micro-
surgery. The problem arises because the sources for maggots and leeches are not reliable.
For this reason, the FDA has classified maggots and leeches as medical devices. Medical
advisers have been asked to create basic guidelines to regulate how maggots and leeches are
grown, transported, sold, and disposed of after use. This will provide a safe source for this
unique method of treatment and encourage future research on the use of maggots and
leeches as methods of treatment. It may also lead to a future in which every microsurgery
has an excellent chance of success.
care workers must stay informed and be prepared 2. Trends in health care: research topics such as
to deal with the consequences of a pandemic. home health care, the Omnibus Budget Recon-
ciliation Act of 1987, telemedicine, holistic
health care, cost containment, geriatric care,
CONCLUSION and wellness to obtain additional information
on the present effect on health care.
Although the preceding are just several of the 3. Complementary/alternative methods of health
many trends in health care, they do illustrate how care: search the Internet for additional infor-
health care has changed and how it will continue mation on specific therapies such as acupunc-
to change. Every health care worker must stay ture. Refer to table 1–8 for a list of many
abreast of such changes and make every attempt different therapies.
to learn about them.
4. Pandemics: search the Internet to obtain
information on at least four (4) pandemics.
STUDENT: Go to the workbook and complete Compare and contrast the cause of each
the assignment sheet for Chapter 1, History and pandemic, the number of people infected, and
Trends of Health Care. the death rate.
REVIEW QUESTIONS
CHAPTER 1 SUMMARY
1. Name the person responsible for each of the
following events in the history of health care.
The history of health care shows that treating ill-
Briefly state how their accomplishments
ness and disease has been an important part of
contributed to the current state of health care.
every civilization. Even in ancient times, people
a. The ancient Greek who is known as the
were searching for ways to eliminate illness and
Father of Medicine
disease. Some of the early plants and herbs that
b. An artist who drew the human body during
were used to treat disease are still in use today.
the Renaissance
Computers and modern technology have caused
c. The inventor of the microscope
major changes in health care in the past century.
d. The individual who discovered roentgeno-
Many more changes are expected in the future
grams (X-rays)
as scientists continue to study the human body
e. The person who discovered penicillin
and discover the causes of illness and disease.
As health care continues to grow as an in- 2. Create a time line for the history of health care
dustry, changes and trends will occur. Issues of showing the twenty (20) events you believe had
primary importance are cost containment to the most impact on modern-day care. State
control the high cost of health care, home health why you believe these events are the most
care, care for the elderly, telemedicine, wellness important.
to prevent disease, complementary and alterna-
3. List six (6) specific ways to control the rising
tive methods (CAM) of health care, a national
cost of health care.
health care plan, and pandemic preparation.
4. You are employed in a medical office with four
doctors. Identify four (4) specific ways to
conserve energy in the office.
INTERNET SEARCHES
5. Write a brief essay describing how you main-
Use the suggested search engines in Chapter 12:4 tain physical, emotional, social, mental, and
of this textbook to search the Internet for addi- spiritual wellness. Be sure to include specific
tional information on the following topics: examples for each type of wellness.
1. History of health care: research individual 6. Review all the CAM therapies shown in table
names or discoveries such as the polio vaccine 1-8. Identify two therapies that you believe
to gain more insight into how major develop- would be beneficial. Explain why you think
ments in health care occurred. the therapies might be effective.
CHAPTER 2 Health Care
Systems
Chapter Objectives
Observe Standard
Precautions
◆ Describe at least eight types of private health
care facilities
◆ Analyze at least three government agencies
and the services offered by each
◆ Describe at least three services offered by
voluntary or nonprofit agencies
Caution ◆ Compare the basic principles of at least four
different health insurance plans
OBRA Requirement—Based ◆ Explain the purpose of organizational
on Federal Law structures in health care facilities
Math Skill
Science Skill
Career Information
Technology
Health Care Systems 27
KEY TERMS
Agency for Health Care home health care Occupational Safety and
Policy and Research hospice Health Administration
(AHCPR) hospitals (OSHA)
assisted living facilities independent living facilities optical centers
Centers for Disease Control industrial health care organizational structure
and Prevention (CDC) centers preferred provider
clinics laboratories organizations (PPOs)
dental offices long-term care facilities rehabilitation
emergency care services (LTCs or LTCFs) school health services
Food and Drug managed care TRICARE
Administration (FDA) Medicaid U.S. Department of Health
genetic counseling centers medical offices and Human Services
health departments Medicare (USDHHS)
health insurance plans Medigap voluntary agencies
Health Insurance Portability mental health Workers’ Compensation
and Accountability Act National Institutes of Health World Health Organization
(HIPAA) (NIH) (WHO)
health maintenance nonprofit agencies
organizations (HMOs)
2:1 INFORMATION HOSPITALS

Private Health Care Facilities Hospitals are one of the major types of health
Today, health care systems include the many care facilities. They vary in size and types of ser-
agencies, facilities, and personnel involved in the vice provided. Some hospitals are small and serve
delivery of health care. According to U.S. govern- the basic needs of a community; others are large,
ment statistics, health care is one of the largest complex centers offering a wide range of services
and fastest-growing industries in the United including diagnosis, treatment, education, and
States. This industry employs over 13 million research. Hospitals are also classified as private
workers in more than 200 different health careers. or proprietary (operated for profit), religious,
It attracts people with a wide range of educational nonprofit or voluntary, and government, depend-
backgrounds because it offers multiple career ing on the sources of income received by the
options. By the year 2012, employment is expected hospital.
to increase to over 15 million workers. Health care There are many different types of hospitals.
has become a 4-billion-dollar-per-day business. Some of the more common ones include:
Many different health care facilities provide
services that are a part of the industry called ♦ General hospitals: treat a wide range of condi-
health care (figure 2-1). Most private health care tions and age groups; usually provide diag-
facilities require a fee for services. In some cases, nostic, medical, surgical, and emergency care
grants and contributions help provide financial services
support for these facilities. A basic description of ♦ Specialty hospitals: provide care for special
the various facilities will help provide an under- conditions or age groups; examples include
standing of the many different types of services burn hospitals, oncology (cancer) hospitals,
included under the umbrella of the health care pediatric (or children’s) hospitals, psychiatric
industry. hospitals (dealing with mental diseases and
28 CHAPTER 1
disorders), orthopedic hospitals (dealing with

bone, joint, or muscle disease), and rehabilita-
tive hospitals (offering services such as physi-
cal and occupational therapy)
♦ Government hospitals: operated by federal,
state, and local government agencies; include
the many facilities located throughout the
world that provide care for government ser-
vice personnel and their dependents; exam-
ples are Veterans Administration hospitals
(which provide care for veterans), state psy-
chiatric hospitals, and state rehabilitation
centers
♦ University or college medical centers: provide
hospital services along with research and edu-
cation; can be funded by private and/or gov-
ernmental sources
In any type of hospital facility, a wide range of
trained health workers is needed at all levels.
LONG-TERM CARE
FACILITIES
Long-term care facilities (LTCs or LTCFs)
mainly provide assistance and care for elderly
patients, usually called residents. However, they
also provide care for individuals with disabilities
or handicaps and individuals with chronic or
long-term illness.
There are many different types of long-term
care facilities. Some of the more common ones
include:
♦ Residential care facilities (nursing homes or
geriatric homes): designed to provide basic
physical and emotional care to individuals
who can no longer care for themselves; help
individuals with activities of daily living
(ADLs), provide a safe and secure environ-
ment, and promote opportunities for social
interactions
♦ Extended care facilities or skilled care facilities:
designed to provide skilled nursing care and
rehabilitative care to prepare patients* or resi-
dents for return to home environments or
other long-term care facilities; some have sub-
acute units designed to provide services to
FIGURE 2-1 Different health care facilities.
*In some health care facilities, patients are referred to
as clients. For the purposes of this text, patient will be
used.
patients who need rehabilitation to recover areas, major retail or department stores operate
from a major illness or surgery, treatment for dental clinics. Dental services can include gen-
cancer, or treatments such as dialysis for kid- eral care provided to all age groups or specialized
ney disease or heart monitoring care offered to certain age groups or for certain
♦ Independent living and assisted living dental conditions.
facilities: allow individuals who can care for
themselves to rent or purchase an apartment
in the facility; provide services such as meals, CLINICS OR SATELLITE
housekeeping, laundry, transportation, social
events, and basic medical care (such as assist-
CENTERS
ing with medications) Clinics, also called satellite clinics or satellite
Most assisted or independent living facilities centers, are health care facilities found in many
are associated with nursing homes, extended care types of health care. Some clinics are composed
facilities, and/or skilled care facilities. This allows of a group of medical or dental doctors who share
an individual to move readily from one level of a facility and other personnel. Other clinics are
care to the next when health needs change. Many operated by private groups who provide special
long-term care facilities also offer special services care. Examples include:
such as the delivery of meals to the homes of the ♦ Surgical clinics or surgicenters: perform minor
elderly, chronically ill, or people with disabilities. surgical procedures; frequently called “one-
Some facilities offer senior citizen or adult day day” surgical centers because patients are sent
care centers, which provide social activities and home immediately after they recover from
other services for the elderly. The need for long- their operation
term care facilities has increased dramatically
because of the large increase in the number of ♦ Urgent or emergency care clinics: provide first
elderly people. Many health career opportunities aid or emergency care to ill or injured patients
are available in these facilities, and there is a ♦ Rehabilitation clinics: offer physical, occupa-
shortage of nurses and other personnel. tional, speech, and other similar therapies
♦ Specialty clinics: provide care for specific dis-
eases; examples include diabetic clinics, kid-
MEDICAL OFFICES ney dialysis centers, and oncology (cancer)
clinics
Medical offices vary from offices that are pri-
♦ Outpatient clinics: usually operated by hospi-
vately owned by one doctor to large complexes
tals or large medical groups; provide care for
that operate as corporations and employ many
outpatients (patients who are not admitted to
doctors and other health care professionals. Medi-
the hospital)
cal services obtained in these facilities can include
diagnosis (determining the nature of an illness), ♦ Health department clinics: may offer clinics
treatment, examination, basic laboratory testing, for pediatric health care, treatment of sexually
minor surgery, and other similar care. Some medi- transmitted diseases and respiratory disease,
cal doctors treat a wide variety of illnesses and age immunizations, and other special services
groups, but others specialize in and handle only ♦ Medical center clinics: usually located in col-
certain age groups or conditions. Examples of spe- leges or universities; offer clinics for various
cialities include pediatrics (infants and children), health conditions; offer care and treatment
cardiology (diseases and disorders of the heart), and provide learning experiences for medical
and obstetrics (care of the pregnant female). students
DENTAL OFFICES OPTICAL CENTERS

Dental offices vary in size from offices that are Optical centers can be individually owned by an
privately owned by one or more dentists to dental ophthalmologist or optometrist or they can be
clinics that employ a group of dentists. In some part of a large chain of stores. They provide vision
30 CHAPTER 2
examinations, prescribe eyeglasses or contact

lenses, and check for the presence of eye diseases.
EMERGENCY CARE
SERVICES
Emergency care services provide special care for
victims of accidents or sudden illness. Facilities
providing these services include ambulance ser-
vices, both private and governmental; rescue
squads, frequently operated by fire departments;
emergency care clinics and centers; emergency
departments operated by hospitals; and helicop-
ter or airplane emergency services that rapidly
transport patients to medical facilities for special
care.
LABORATORIES
Laboratories are often a part of other facilities FIGURE 2-2 Many types of health care can be
but can operate as separate health care services. provided in a patient’s home.
Medical laboratories can perform special diag-
nostic tests such as blood or urine tests. Dental palliative care, or care that provides support and
laboratories can prepare dentures (false teeth) comfort, that is directed toward allowing the per-
and many other devices used to repair or replace son to die with dignity. Psychological, social, spir-
teeth. Medical and dental offices, small hospitals, itual, and financial counseling are provided for
clinics, and many other health care facilities fre- both the patient and the family. Hospice also pro-
quently use the services provided by laboratories. vides support to the family following a patient’s
death.
HOME HEALTH CARE

MENTAL HEALTH
Home health care agencies are designed to
provide care in a patient’s home (figure 2-2). The FACILITIES
services of these agencies are frequently used by
Mental health facilities treat patients with men-
the elderly and disabled. Examples of such ser-
tal disorders and diseases. Examples of these
vices include nursing care, personal care, therapy
facilities include guidance and counseling cen-
(physical, occupational, speech, respiratory), and
ters, psychiatric clinics and hospitals, chemical
homemaking (food preparation, cleaning, and
abuse treatment centers (dealing with alcohol
other household tasks). Health departments,
and drug abuse), and physical abuse treatment
hospitals, private agencies, government agen-
centers (dealing with child abuse, spousal abuse,
cies, and nonprofit or volunteer groups can offer
and geriatric [elderly] abuse).
home care services.
HOSPICE GENETIC COUNSELING

Hospice agencies provide care for terminally ill
CENTERS
persons who usually have life expectancies of 6 Genetic counseling centers can be an inde-
months or less. Care can be provided in the per- pendent facility or located in another facility such
son’s home or in a hospice facility. Hospice offers as a hospital, clinic, or physician’s office. Genetic
counselors work with couples or individuals who for employees of the industry or business by per-
are pregnant or considering a pregnancy. They forming basic examinations, teaching accident
perform prenatal (before birth) screening tests, prevention and safety, and providing emergency
check for genetic abnormalities and birth defects, care.
explain the results of the tests, identify medical
options when a birth defect is present, and help
the individuals cope with the psychological issues
caused by a genetic disorder. Examples of genetic
SCHOOL HEALTH
disorders include Down’s syndrome and cystic SERVICES
fibrosis. Counselors frequently consult with cou-
ples prior to a pregnancy if the woman is in her School health services are found in schools
late childbearing years, has a family history of and colleges. These services provide emergency
genetic disease, or is of a specific race or nation- care for victims of accidents and sudden illness;
ality with a high risk for genetic disease. perform tests to check for health conditions such
as speech, vision, and hearing problems; pro-
mote health education; and maintain a safe and
REHABILITATION sanitary school environment. Many school health
services also provide counseling.
FACILITIES
Rehabilitation facilities are located in hospi-
tals, clinics, and/or private centers. They provide
2:2 INFORMATION
care to help patients with physical or mental dis- Government Agencies
abilities obtain maximum self-care and function.
Services may include physical, occupational, rec- In addition to the government health care facilities
reational, speech, and hearing therapy. mentioned previously, other health services are
offered at international, national, state, and local
levels. Government services are tax supported.
HEALTH MAINTENANCE Examples of government agencies include:
♦ World Health Organization (WHO): an
ORGANIZATIONS international agency sponsored by the United
Health maintenance organizations (HMOs) Nations; compiles statistics and information
are both health care delivery systems and types of on disease, publishes health information, and
health insurance. They provide total health care investigates and addresses serious health
directed toward preventive health care for a fee problems throughout the world
that is usually fixed and prepaid. Services include ♦ U.S. Department of Health and Human
examinations, basic medical services, health Services (USDHHS): a national agency that
education, and hospitalization or rehabilitation deals with the health problems in the United
services as needed. Some HMOs are operated by States
large industries or corporations; others are oper- ♦ National Institutes of Health (NIH): a divi-
ated by private agencies. They often use the ser- sion of the USDHHS; involved in research on
vices of other health care facilities including disease
medical and dental offices, hospitals, rehabilita-
tive centers, home health care agencies, clinics, ♦ Centers for Disease Control and Preven-
and laboratories. tion (CDC): another division of the USDHHS;
concerned with causes, spread, and control of
diseases in populations
INDUSTRIAL HEALTH ♦ Food and Drug Administration (FDA): a
CARE CENTERS federal agency responsible for regulating food
and drug products sold to the public
Industrial health care centers or occupa- ♦ Agency for Health Care Policy and
tional health clinics are found in large companies Research (AHCPR): a federal agency estab-
or industries. Such centers provide health care lished in 1990 to research the quality of health
32 CHAPTER 2
care delivery and identify the standards of Nonprofit agencies employ many health care
treatment that should be provided by health workers in addition to using volunteer workers to
care facilities provide services.
♦ Occupational Safety and Health Admin-
istration (OSHA): establishes and enforces
standards that protect workers from job-
2:4 INFORMATION
related injuries and illnesses Health Insurance Plans
♦ Health departments: provide health ser- The cost of health care is a major concern of
vices as directed by the U.S. Department of everyone who needs health services. Statistics
Health and Human Services (USDHHS); also show that the cost of health care is more than 15
provide specific services needed by the state percent of the gross national product (the total
or local community; examples of services amount of money spent on all goods and ser-
include immunization for disease control, vices). Also, health care costs are increasing much
inspections for environmental health and faster than other costs of living. To pay for the
sanitation, communicable disease control, costs of health care, most people rely on health
collection of statistics and records related to insurance plans. Without insurance, the cost
health, health education, clinics for health of an illness can mean financial disaster for an
care and prevention, and other services individual or family.
needed in a community Health insurance plans are offered by several
thousand insurance agencies. A common exam-
ple is Blue Cross/Blue Shield (figure 2-3). In this
2:3 INFORMATION type of plan, a premium, or a fee the individual
pays for insurance coverage, is made to the insur-
Voluntary or Nonprofit Agencies ance company. When the insured individual
Voluntary agencies, frequently called non- incurs health care expenses covered by the insur-
profit agencies, are supported by donations, ance plan, the insurance company pays for the
membership fees, fund-raisers, and federal or services. The amount of payment and the type of
state grants. They provide health services at services covered vary from plan to plan. Com-
national, state, and local levels. mon insurance terms include:
Examples of nonprofit agencies include the ♦ Deductibles: amounts that must be paid by the
American Cancer Society, American Heart Asso- patient for medical services before the policy
ciation, American Respiratory Disease Associa- begins to pay
tion, American Diabetes Association, National
Mental Health Association, Alzheimer’s Associa- ♦ Co-insurance: requires that specific percent-
tion, National Kidney Foundation, Leukemia and ages of expenses are shared by the patient and
Lymphoma Society, National Foundation of the insurance company; for example, in an 80–20
March of Dimes, and American Red Cross. Many percent co-insurance, the company pays 80
of these organizations have national offices as
well as branch offices in states and/or local com-
munities.
As indicated by their names, many such orga-
nizations focus on one specific disease or group
of diseases. Each organization typically studies
the disease, provides funding to encourage
research directed at curing or treating the dis-
ease, and promotes public education regarding
information obtained through research. These
organizations also provide special services to vic-
tims of disease, such as purchasing medical
equipment and supplies, providing treatment FIGURE 2-3 Health insurance plans help pay for
centers, and supplying information regarding the costs of health care. (Courtesy of Empire Blue
other community agencies that offer assistance. Cross/Blue Shield)
percent of covered expenses, and the patient Medicare is a federal government program
pays the remaining 20 percent that provides health care for almost all individu-
♦ Co-payment: a specific amount of money a als over the age of 65, for any person with a dis-
patient pays for a particular service, for exam- ability who has received Social Security benefits
ple, $10 for each physician visit regardless of for at least 2 years, and for any person with end-
the total cost of the visit stage renal (kidney) disease. Medicare consists of
three kinds of coverage: type A for hospital insur-
ance, type B for medical insurance, and type D
Many individuals have insurance coverage for pharmaceutical (medication) expenses. Type
through their places of employment (called A covers hospital services, care provided by an
employer-sponsored health insurance or group extended care facility or home-health care agency
insurance), where the premiums are paid by the after hospitalization, and hospice care for people
employer. In most cases, the individual also pays with a terminal illness. Type B offers additional
a percentage of the premium. Private policies are coverage for doctors’ services, outpatient treat-
also available for purchase by individuals. ments, therapy, clinical laboratory services, and
A health maintenance organization (HMO) is other health care. The individual does pay a pre-
another type of health insurance plan that pro- mium for type B coverage and also must pay an
vides a managed care plan for the delivery of initial deductible for services. In addition, Medi-
health care services. A monthly fee or premium is care pays for only 80 percent of the services; the
paid for membership, and the fee stays the same individual must either pay the balance or have
regardless of the amount of health care used. The another insurance policy to cover the expenses.
premium can be paid by an employer and/or an Medigap policies are health insurance plans
individual. Total care provided is directed toward that help pay expenses not covered by Medicare.
preventive type health care. An individual insured These policies are offered by private insurance
under this type of plan has ready access to health companies and require the payment of a pre-
examinations and early treatment and detection mium by the enrollee. Medigap policies must
of disease. Because most other types of insurance meet specific federal guidelines. They provide
plans do not cover routine examinations and pre- options that allow enrollees to choose how much
ventive care, the individual insured by an HMO coverage they want to purchase.
can therefore theoretically maintain a better state Medicaid is a medical assistance program
of health. The disadvantage of an HMO is that the that is jointly funded by the federal government
insured is required to use only HMO-affiliated and state governments but operated by individ-
health care providers (doctors, laboratories, hos- ual states. Benefits and individuals covered under
pitals) for health care. If a nonaffiliated health this program vary slightly from state to state
care provider is used instead, the insured usually because each state has the right to establish its
must pay for the care. own eligibility standards, determine the type and
A preferred provider organization scope of services, set the rate of payment for ser-
(PPO) is another type of managed care health vices, and administer its own program. In most
insurance plan usually provided by large indus- states, Medicaid pays for the health care of indi-
tries or companies to their employees. The PPO viduals with low incomes, children who qualify
forms a contract with certain health care agen- for public assistance, and individuals who are
cies, such as a large hospital and/or specific doc- physically disabled or blind. Generally, all state
tors and dentists, to provide certain types of Medicaid programs provide hospital services,
health care at reduced rates. Employees are physician’s care, long-term care services, and
restricted to using the specific hospital and/or some therapies. In some states, Medicaid offers
doctors, but the industry or company using the dental care, eye care, and other specialized ser-
PPO can provide health care at lower rates. PPOs vices.
usually require a deductible and a co-payment. If The State Children’s Health Insurance Pro-
an enrollee uses a nonaffiliated provider, the PPO gram (SCHIP) was established in 1997 to provide
may require co-payments of 40–60 percent. health care to uninsured children of working
The government also provides health insur- families who earn too little to afford private insur-
ance plans for certain groups of people. Two of ance but too much to be eligible for Medicaid. It
the main plans are Medicare and Medicaid. provides inpatient and outpatient hospital ser-
34 CHAPTER 2
vices, physician’s surgical and medical care, labo- ance increases, many employers are less willing
ratory and X-ray tests, and well-baby and to offer health care insurance. Individuals with
well-child care, including immunizations. chronic illnesses often find they cannot obtain
Workers’ Compensation is a health insur- insurance coverage if their place of employment
ance plan providing treatment for workers injured changes. This is one reason the federal govern-
on the job. It is administered by the state, and ment passed the Health Insurance Portabil-
payments are made by employers and the state. ity and Accountability Act (HIPAA) in 1996.
In addition to providing payment for needed This act has five main components:
health care, this plan also reimburses the worker
♦ Health Care Access, Portability, and Renew-
for wages lost because of on-the-job injury.
ability: limits exclusions on preexisting condi-
TRICARE, formerly called CHAMPUS (the
tions to allow for the continuance of insurance
Civilian Health and Medical Programs for the
even with job changes, prohibits discrimina-
Uniform Services) is a U.S. government health
tion against an enrollee or beneficiary based
insurance plan for all military personnel. It pro-
on health status, guarantees renewability in
vides care for all active duty members and their
multiemployer plans, and provides special
families, survivors of military personnel, and
enrollment rights for individuals who lose
retired members of the Armed Forces. The Veter-
insurance coverage in certain situations such
ans Administration provides for military veter-
as divorce or termination of employment
ans.
Managed care is an approach that has ♦ Preventing Health Care Fraud and Abuse;
developed in response to rising health care costs. Administrative Simplification, and Medical
Employers, as well as insurance companies who Liability Reform: establishes methods for pre-
pay large medical bills, want to ensure that such venting fraud and abuse and imposes sanc-
money is spent efficiently rather than wastefully. tions or penalties if fraud or abuse does occur,
The principle behind managed care is that all reduces the costs and administration of health
health care provided to a patient must have a care by adopting a single set of electronic
purpose. A second opinion or verification of need standards to replace the wide variety of for-
is frequently required before care can be pro- mats used in health care, provides strict guide-
vided. Every effort is made to provide preventive lines for maintaining the confidentiality of
care and early diagnosis of disease to avoid the health care information and the security of
high cost of treating disease. For example, rou- health care records, and recommends limits
tine physical examinations, well-baby care, for medical liability
immunizations, and wellness education to pro- ♦ Tax-Related Health Provisions: promotes the
mote good nutrition, exercise, weight control, use of medical savings accounts (MSAs) by
and healthy living practices are usually provided allowing tax deductions for monies placed in
under managed care. Employers and insurance the accounts, establishes standards for long-
companies create a network of doctors, special- term care insurance, allows for the creation of
ists, therapists, and health care facilities that prostate insurance pools, and provides tax bene-
vide care at the most reasonable cost. HMOs and fits for some health care expenses
PPOs are the main providers of managed care, ♦ Application and Enforcement of Group Health
but many private insurance companies are estab- Plan Requirements: establishes standards that
lishing health care networks to provide care to require group health care plans to offer porta-
their subscribers. As these health care networks bility, access, and renewability to all members
compete for the consumer dollar, they are of the group
required to provide quality care at the lowest pos-
sible cost. The health care consumer who is
♦ Revenue Offsets: provides changes to the Inter-
nal Revenue Code for HIPAA expenses
enrolled in a managed care plan receives quality
care at the most reasonable cost but is restricted Compliance with all HIPAA regulations was
in choice of health care providers. required by April 2004 for all health care agencies.
Health insurance plans do not solve all the These regulations have not solved all of the prob-
problems of health care costs, but they do help lems of health care insurance, but they have pro-
many people by paying for all or part of the cost vided consumers with more access to insurance
of health services. However, as the cost of insur- and greater confidentiality in regard to medical
records. In addition, standardization of electronic A sample organizational chart for a large gen-
health care records, reductions in administrative eral hospital is shown in figure 2-4. This chart
costs, increased tax benefits, and decreasing shows organization by department. Each depart-
fraud and abuse in health care have reduced ment, in turn, can have an organizational chart
health care costs for everyone. similar to the one shown for the nursing depart-
ment in figure 2-4. A sample organizational chart
for a small medical office is shown in figure 2-5.
2:5 INFORMATION The organizational structure will vary with the size
of the office and the number of people employed.
Organizational Structure In both organizational charts illustrated, the
All health care facilities must have some type of lines of authority are clearly indicated. It is impor-
organizational structure. The structure may tant for health care workers to identify and under-
be complex, as in larger facilities, or simple, as in stand their respective positions in a given facility’s
smaller facilities. Organizational structure always, organizational structure. By doing this, they will
however, encompasses a line of authority or chain know their lines of authority and understand who
of command. The organizational structure should are the immediate supervisors in charge of their
indicate areas of responsibility and lead to the work. Health care workers must always take ques-
most efficient operation of the facility. tions, reports, and problems to their immediate
Hospital Board
Medical Staff
Hospital Director
(President)
(Administrator)
Maintenance Central Business

Housekeeping Supply Office Pharmacy Dietary Nursing Laboratory Radiology Therapy Volunteers
Public Medical Social

Administration Personnel Relations Accounts Records Services Physical Occupational Recreational
Director
(Vice President)
of Nurses
Nursing Surgery Inpatient Care Emergency Clinics

Education Room
Nursing Supervisors
R.N.’s
Head or Charge
Nurses
(Unit Managers)
Patient Care Ward Clerks

Technicians L.P.N.’s R.N.’s or Volunteers
(PCTs) L.V.N.’s Unit Coordinators
FIGURE 2-4 A sample hospital organizational chart.

36 CHAPTER 2
Doctor
Office
Manager
Administrative
Assistant R.N.’s Maintenance Business Dept.
Laboratory
(Receptionist) Housekeeping Insurance
L.P.N.’s Medical
L.V.N.’s Assistants
FIGURE 2-5 A sample medical office organizational chart.

Nature as a pharmacy?
Throughout history, many medicines have been derived from natural resources. Exam-
ples include aspirin, which comes from willow bark; penicillin, which comes from fungus;
and the cancer drug Taxol, which comes from the Pacific yew tree. Recognizing this, many
scientists believe that nature is a pharmaceutical gold mine and are exploring the vast sup-
ply of materials present in the oceans and in the earth.
The National Cancer Institute (NCI) has more than 100,000 samples of plants and marine
life stored in Frederick, Maryland. Every sample is crushed into a powder and made into
extracts that can be tested against human cancer cells. In addition, small quantities of the
extracts are made available to other scientists who evaluate their effectiveness against other
conditions, such as viral diseases and infections. To date, more than 4,000 extracts have
shown promise and are being used in more advanced studies. One compound, Halichon-
drin B, labeled “yellow slimy” by researchers, appears to be effective at eliminating human
tumors. Halichondrin B is an extract taken from a deep-sea sponge found in New Zealand.
Scientists have created a synthetic version of the active component in Halichondrin B. This
component, called E7389, is currently being tested in patients with a variety of tumors. By
creating synthetic versions of the compounds, scientists are preserving natural resources
while also benefiting from them.
Other natural products are now being tested and modified. Bristol-Myers is testing Ixa-
bepilone, extracted from garden soil bacteria, in patients with advanced breast cancer.
Wyeth isolated Rapamune from soil on Easter Island and proved it is effective in preventing
kidney rejection after transplants. NCI developed a compound called prostratin from tree
bark in Samoa. Healers in Samoa used the bark to treat hepatitis. The NCI has found that it
is effective against the human immunodeficiency virus (HIV) that causes acquired immune
deficiency syndrome (AIDS). As scientists continue to explore all that nature has to offer, it
is possible they will find cures for many cancers, diseases, and infections.
supervisors, who are responsible for providing tutes of Health, Centers for Disease Control
necessary assistance. If immediate supervisors and Prevention, Food and Drug Administra-
cannot answer the question or solve the problem, tion, and Occupational Safety and Health
it is their responsibility to take the situation to the Administration.
next level in the organizational chart. It is also 3. Voluntary or nonprofit agencies: search for
important for health care workers to understand information on the purposes and activities of
the functions and goals of the organization. organizations such as the American Cancer
Society, American Heart Association, American
STUDENT: Go to the workbook and complete Respiratory Disease Association, American
the assignment sheet for Chapter 2, Health Care Diabetes Association, National Mental Health
Systems. Association, National Foundation of the March
of Dimes, and the American Red Cross.
4. Health insurance: search the Internet to find
CHAPTER 2 SUMMARY specific names of companies that are health
maintenance organizations or preferred
provider organizations. Check to see how their
Health care, one of the largest and fastest grow-
coverage for individuals is the same or how it is
ing industries in the United States, encompasses
different.
many different types of facilities that provide
health-related services. These include hospitals, 5. Government health care insurance: search the
long-term care facilities, medical and dental of- Internet to learn about benefits provided
fices, clinics, laboratories, industrial and school under Medicare, Medicaid, and the State
health services, and many others. Government Children’s Health Insurance Program.
and nonprofit or voluntary agencies also pro-
vide health care services. All health care facili-
ties require different health care workers at all REVIEW QUESTIONS
levels of training.
Many types of health insurance plans are 1. Differentiate between a private or proprietary,
available to help pay the costs of health care. religious, nonprofit or voluntary, and govern-
Insurance does not usually cover the entire cost ment type of hospital.
of care, however. It is important for consumers 2. Identify at least six (6) different types of private
to be aware of the types of coverage provided by health care facilities by stating the functions of
their respective insurance plans. the facility. Provide specific examples of the
Organizational structure is important in all care received at each facility.
health care facilities. The structure can be com-
plex or simple, but it should show a line of au- 3. Name each of the following federal agencies
thority or chain of command within the facility and briefly describe its function:
and indicate areas of responsibility. a. CDC
b. FDA
c. NIH
INTERNET SEARCHES d. OSHA
e. USDHHS
Use the suggested search engines in Chapter 12:4 f. WHO
of this textbook to search the Internet for addi- 4. What does the term deductible mean on health
tional information on the following topics: insurance policies? co-insurance? co-payment?
1. Private health care facilities: search for infor- premium?
mation on each of the specific types of facili- 5. An insurance policy has a co-payment of 70–30
ties; for example, hospitals, hospice care, or percent. If an emergency department bill is
emergency care services. $660.00, what amount will the patient have to
2. Government agencies: search for more detailed pay?
information about the activities of the World 6. Why is it important for every health care
Health Organization, U.S. Department of worker to know the organizational structure for
Health and Human Services, National Insti- his/her place of employment?
CHAPTER 3 Careers in Health
Care
Chapter Objectives
Observe Standard
Precautions
◆ Compare the educational requirements for
associate’s, bachelor’s, and master’s degrees
◆ Contrast certification, registration, and
licensure
◆ Describe at least 10 different health careers by
including a definition of the career, three
Caution
duties, educational requirements, and
employment opportunities
◆ Investigate at least one health career by writing
on Federal Law
to listed sources or using the Internet to
request additional information on the career
◆ Interpret at least 10 abbreviations used to
Math Skill
identify health care career workers
◆ Define, pronounce, and spell all key terms (see
page 3 for explanation of accent mark use)
Science Skill
Career Information
Technology
Careers in Health Care 39
KEY TERMS
admitting officers/clerks electrocardiograph (ECG) medical illustrators
art, music, dance therapists technicians medical interpreters/
associate’s degree (ee-lek⬙-trow-car⬘-dee-oh- translators
athletic trainers (ATs) graf tek-nish⬘-ins) medical (clinical) laboratory
audiologists electroencephalographic assistants
(EEG) technologist medical (clinical) laboratory
bachelor’s degree
(ee-lek⬙-troh-en-sef-ahl-oh- technicians (MLTs)
biological or medical graf⬘-ik tek-nahl⬘-oh-jist)
scientists medical (clinical) laboratory
electroneurodiagnostic technologists (MTs)
biological technician technologist (END)
biomedical (clinical) medical librarians
(ee-lek⬙-troh-new-roh-die-
engineer medical transcriptionists
ag-nah⬘-stik)
biotechnological engineer medication aides/assistants
embalmers (em-bahl⬘-mers)
(bioengineer) mortuary assistants
emergency medical
biomedical equipment technician (EMT) multicompetent/
technicians (BETs) multiskilled worker
endodontics
cardiovascular technologist (en⬘-doe-don⬘-tiks) nurse assistants
central/sterile supply entrepreneur occupational therapists
workers (on⬙trah-peh-nor⬘) (OTs)
certification epidemiologists occupational therapy
continuing education units assistants (OTAs)
first responder
(CEUs) ophthalmic assistants (OAs)
forensic science technician
dental assistants (DAs) ophthalmic laboratory
funeral directors
dental hygienists technicians
genetic counselors
(den⬘-tall hi-geen⬘-ists) ophthalmic medical
geriatric aides/assistants technologists (OMTs)
dental laboratory (jerry-at⬘-rik)
technicians (DLTs) ophthalmic technicians
health care administrators (OTs)
dentists (DMDs or DDSs)
health information (medical ophthalmologists
dialysis technicians (die- records) administrators
ahl⬘-ih-sis tek-nish⬘ins) opticians (ahp-tish⬘-ins)
(RAs)
dietetic assistants optometrists (ODs)
health information (medical
dietetic technicians (DTs) (ah⬘-tom⬘-eh-trists)
records) technicians
dietitians (RDs) oral surgery
health science technology
Doctor of Chiropractic (DC) education (HSTE) orthodontics
(Ky-row-prak⬘-tik) (or⬙-thow-don⬘-tiks)
home health care assistants
Doctor of Medicine (MD) paramedic (EMT-P)
housekeeping workers/
Doctor of Osteopathic sanitary managers patient care technicians
Medicine (DO) (PCTs)
licensed practical/vocational
(Oss-tee-ohp⬘-ath-ik) nurses (LPNs/LVNs) pedodontics
Doctor of Podiatric Medicine (peh⬙-doe-don⬘-tiks)
licensure (ly⬘-sehn-shur)
(DPM) (Poh⬙-dee⬘-ah-trik) perfusionists
massage therapists
doctorate/doctoral/doctor’s (purr-few⬘-shun-ists)
master’s degree
degree
medical assistants (MAs)
40 CHAPTER 3
KEY TERMS
periodontics psychiatric/mental health respiratory therapy
(peh⬙-ree-oh-don⬘-tiks) technicians technicians (RTTs)
pharmacists (PharmDs) psychiatrists social workers (SWs)
(far⬘-mah-sists) psychologists speech–language
pharmacy technicians (sy-koll⬙-oh-jists) pathologists
phlebotomists radiologic technologists surgical technologists/
physical therapists (PTs) (RTs) (ray⬙-dee-oh-loge⬘-ik technicians (STs)
physical therapist assistants tek-nahl⬘-oh-jists) unit secretaries/ward clerks/
(PTAs) recreational therapists (TRs) unit coordinators
physicians recreational therapy veterinarians (DVMs or
physician assistants (PAs) assistants VMDs)
process technician registered nurses (RNs) (vet⬙-eh-ran-air⬘-e-ans)
prosthodontics registration veterinary assistants
(pross⬙-thow-don⬘-tiks) respiratory therapists (RTs) veterinary technologists/
technicians (VTs)
years of work beyond a bachelor’s degree. Other

3:1 INFORMATION careers require a doctorate, doctoral, or doc-
tor’s degree, which is awarded by a college or
Introduction to Health Careers university after completion of two or more years
There are more than 250 different health care of work beyond a bachelor’s or master’s degree.
careers, so it would be impossible to discuss all of Some doctorates can require four to six years of
them in this chapter. A broad overview of a vari- additional study.
ety of careers is presented, however. A health science career cluster has been
Educational requirements for health developed by the National Consortium on Health
careers depend on many factors and Science and Technology Education (NCHSTE)
can vary from state to state. Basic preparation (figure 3-1). This cluster allows a student to see
begins in high school (secondary education) and how early career awareness and exploration pro-
should include the sciences, social studies, Eng- vide the foundation for making informed choices
lish, and mathematics. Keyboarding, computer to prepare for a career in health care. Students
applications, and accounting skills are also uti- who take required courses in middle school and
lized in most health occupations. Secondary high school have the foundation for success at
health science technology education the post-secondary level.
(HSTE) programs can prepare a student for imme-
diate employment in many health careers or for
additional education after graduation. Post-sec- CERTIFICATION,
ondary education (after high school) can include
training in a career/technical school, community REGISTRATION,
college, or university. Some careers require an
associate’s degree, which is awarded by a
AND LICENSURE
career/technical school or a community college Three other terms associated with health careers
after completion of a prescribed two-year course are certification, registration, and licensure. These
of study. Other careers require a bachelor’s are methods used to ensure the skill and compe-
degree, which is awarded by a college or univer- tency of health care personnel and to protect the
sity after a prescribed course of study that usually consumer or patient.
lasts for four or more years. In some cases, a mas- Certification means that a person has ful-
ter’s degree is required. This is awarded by a col- filled requirements of education and performance
lege or university after completion of one or more and meets the standards and qualifications estab-
and retaining licensure usually requires that a

HEALTH SCIENCE CAREER CLUSTER person complete an approved educational pro-
gram, pass a state board test, and maintain cer-
Employment in Career Specialties tain standards. Examples of licensed positions
CAREER PREPARATION include physician, dentist, physical therapist,
registered nurse, and licensed practical/voca-
POST SECONDARY
WORK PLACE
PATHWAY STANDARDS
Diagnostic Health tional nurse.
Therapeutic Informatics
Support
Biotechnology
Research and
Services ACCREDITATION
Development
For most health careers, graduation from an
PLACES OF LEARNING
PLACES OF LEARNING
accredited program is required before certifica-
WORK PLACE
CAREER ORIENTATION/PREPARATION tion, registration, and/or licensure will be granted.
HIGH SCHOOL
CLUSTER FOUNDATION STANDARDS Accreditation ensures that the program of study

Academic Safety Practices meets the established quality competency stan-
Foundation Teamwork dards and prepares students for employment in
Communications Health the health career. It is important for a student to
Systems Maintenance make sure that a technical school, college, or uni-
Practices
Employability versity offers accredited programs of study before
MIDDLE
Skills Technical Skills enrolling. Two major accrediting agencies for

Legal Information health care programs are the Commission on
Responsibilities Technology
Applications
Accreditation of Allied Health Education Pro-
Ethics grams (CAAHEP) and the Accrediting Bureau of
ELEMENTARY
CAREER EXPLORATION/ ORIENTATION Health Education Schools (ABHES). A student can

contact these agencies to determine whether an
HSTE program at a specific school is accredited.
CAREER AWARENESS
FIGURE 3-1 This cluster shows how early career

awareness and exploration can provide a foundation
CONTINUING
for making informed choices to prepare for a career EDUCATION UNITS
in health care.
Continuing education units (CEUs) are
required to renew licenses or maintain cer-
lished by the professional association or govern- tification or registration in many states (figure
ment agency that regulates a particular career. 3-2). An individual must obtain additional hours
A certificate or statement is issued by the asso- of education in the specific health career area
ciation. Examples of certified positions include during a specified period. For example, many
certified dental assistant, certified laboratory states require registered nurses to obtain 24 to 48
technician, and certified medical assistant. CEUs every 1 to 2 years to renew licenses. Health
Registration is required in some health care care workers should be aware of the state require-
careers. This is performed by a regulatory body ments regarding CEUs for their given careers.
(professional association or state board) that
administers examinations and maintains a cur-
rent list (“registry”) of qualified personnel in a EDUCATION LEVELS,
given health care area. Examples of registered
positions include registered dietitian, registered TRENDS, AND
respiratory therapist, and registered radiologic
technologist.
OPPORTUNITIES
Licensure is a process whereby a govern- Generally speaking, training for most health care
ment agency authorizes individuals to work in a careers can be categorized into four levels: pro-
given occupation. Health care careers requiring fessional, technologist or therapist, technician,
licensure can vary from state to state. Obtaining and aide or assistant, as shown in table 3-1.
42 CHAPTER 3
cardiograph (ECG) technician (who records

electrical activity of the heart) and an electroen-
cephalographic (EEG) technologist (who records
electrical activity of the brain). Another example
might involve combining the basic skills of radi-
ology, medical (clinical) laboratory, and respira-
tory therapy. At times, workers trained in one
field or occupation receive additional education
to work in a second and even third occupation. In
other cases, educational programs have been
established to prepare multicompetent workers.
Another opportunity available in many health
occupations is that of entrepreneur. An entre-
preneur is an individual who organizes, man-
ages, and assumes the risk of a business. Some
health care careers allow an individual to work as
an independent entrepreneur, while others
encourage the use of groups of cooperating indi-
viduals. Many entrepreneurs must work under
the direction or guidance of physicians or den-
tists. Because the opportunity to be self-employed
FIGURE 3-2 Continuing education units (CEUs) and to be involved in the business area of health
are required to renew licenses or maintain certifica- care exists, educational programs are including
tion or registration in many states. business skills with career objectives. A common
example is combining a bachelor’s degree in a
specific health care career with a master’s degree
A common trend in health care is the multi- in business. Some health care providers who may
competent or multiskilled worker. Because be entrepreneurial include dental laboratory tech-
of high health care costs, smaller facilities and nicians, dental hygienists, nurse practitioners,
rural areas often cannot afford to hire a specialist physical therapists, physician assistants, respira-
for every aspect of care. Therefore, workers tory therapists, recreational therapists, physicians,
are hired who can perform a variety of health dentists, chiropractors, and optometrists. Although
care skills. For example, a health care worker may entrepreneurship involves many risks and requires
be hired to perform the skills of both an electro- a certain level of education and ability, it can be an
TABLE 3-1 Education and Levels of Training

CAREER LEVEL EDUCATIONAL REQUIREMENT EXAMPLES
Professional Four or more years of college with bachelor’s, master’s, Medical doctor
or doctoral degree Dentist
Technologist Three to four years of college plus work experience, Medical (clinical) laboratory technologist
or Therapist usually bachelor’s degree and, at times, master’s Physical therapist
degree Speech therapist
Respiratory therapist
Technician Two-year associate’s degree, special health science Dental laboratory technician
technology education, or three to four years of on- Medical (clinical) laboratory technician
the-job training Surgical technician
Aide or Assistant Specific number of hours of specialized education or Dental assistant
one or more years of training combining classroom Medical assistant
and/or on-the-job training Nurse assistant
extremely satisfying choice for the individual who ♦ Health Informatics Services Cluster Standards:
is well motivated, self-confident, responsible, cre- specify the knowledge and skills required of
ative, and independent. workers in health care careers that are involved
with the documentation of patient care;
includes communicating information accu-
NATIONAL HEALTH rately within legal boundaries, analyzing
CARE SKILL STANDARDS information, abstracting and coding medical
records and documents, designing and/or
The National Health Care Skill Standards (NHCSS) implementing effective information systems,
were developed to indicate the knowledge and documenting information, and understand-
skills that are expected of health care workers pri- ing operations to enter, retrieve, and maintain
marily at entry and technical levels. The seven information
groups of standards include the following: ♦ Support (Environmental) Services Cluster
♦ Health Care Core Standards: specify the knowl- Standards: specify the knowledge and skills
edge and skills that most health care workers required of workers in health care careers that
should have; discuss an academic foundation, are involved with creating a therapeutic envi-
communication skills, employability skills, ronment to provide direct or indirect patient
legal responsibilities, ethics, safety practices, care; include developing and implementing
teamwork, information technology applica- the administration, quality control, and com-
tions, technical skills, health maintenance pliance regulations of a health care facility;
practices, and knowledge about the systems maintaining a clean and safe environment
in the health care environment through aseptic techniques; managing re-
sources; and maintaining an aesthetically
♦ Therapeutic/Diagnostic Core Standards: spec- appealing environment
ify the knowledge and skills required to focus
on direct patient care in both the therapeutic ♦ Biotechnology Research and Development
and diagnostic health care careers; include Standards: specify the knowledge and skills
health maintenance practices, patient inter- required of workers in health care careers that
action, intrateam communication, monitor- are involved in bioscience research and devel-
ing patient status, and patient movement opment; include comprehending how bio-
technology contributes to health and the
♦ Therapeutic Cluster Standards (Therapeutic quality of life, developing a strong foundation
Services): specify the knowledge and skills in math and science principles, performing
required of workers in health care careers that biotechnology techniques, understanding and
are involved in changing the health status of following laboratory protocols and principles,
the patient over time; include interacting with working with product design and develop-
patients, communicating with team members, ment, and complying with bioethical policies
collecting information, planning treatment,
implementing procedures, monitoring patient Examples of some of the health careers
status, and evaluating patient response to included in the NHCSS Clusters are shown in
treatment table 3-2. The careers listed are discussed in detail
in this chapter.
♦ Diagnostic Cluster Standards (Diagnostic Ser-
vices): specify the knowledge and skills
required of workers in health care careers that
are involved in creating a picture of the health INTRODUCTION TO
status of the patient at a single point in time;
include communicating oral and written
HEALTH CAREERS
information, assessing patient’s health status, In the following discussion of health careers, a
moving and positioning patients safely and basic description of the job duties for each career
efficiently, explaining procedures and goals, is provided. The various levels in each health care
preparing for procedures, performing diag- career are also given. In addition, tables for each
nostic procedures, evaluating test results, and career group show educational requirements, job
reporting required information outlook, and average yearly earnings.
44
CHAPTER 3
TABLE 3-2 Health Science Center Pathways
Planning, managing, and providing therapeutic services, diagnostic services, health informatics, support services, and biotechnology research and development
Pathways
Therapeutic Diagnostics Health Support Biotechnology Research

Services Services Informatics Services and Development
Sample Career Specialties/Occupations
Acupuncturist Cardiovascular technologist Admitting clerk Biomedical/clinical Biochemist

Anesthesiologist assistant Clinical lab technician Applied researcher engineer Bioinformatics associate
Art/music/dance therapist Computer tomography (CT) Community services Biomedical/clinical Bioinformatics specialist
Athletic trainer technologist specialist technician Biomedical chemist
Audiologist Cytogenetic technologist Data analyst Central services Biostatistician
Certified nursing assistant Cytotechnologist Epidemiologist Environmental health Cell biologist
Chiropractor Diagnostic medical Ethicist and safety Clinical trials research
Dental assistant/hygienist sonographer Health educator Environmental services associate
Dental lab technician Electrocardiographic (ECG) Health information coder Facilities manager Clinical trials research
Dentist technician Health information services Food service coordinator
Dietician Electronic diagnostic (EEG) Health care administrator Hospital maintenance Geneticist
Dosimetrist technologist Medical assistant engineer Lab assistant—genetics
EMT Exercise physiologist Medical biller/patient financial Industrial hygienist Lab technician
Exercise physiologist Geneticist services Materials management Microbiologist
Home health aide Histotechnologist Medical information Transport technician Molecular biologist
Kinesiotherapist Magnetic resonance (MR) technologist Pharmaceutical scientist
Licensed practical nurse technologist Medical librarian/cybrarian Quality assurance technician
Massage therapist Mammographer Patient advocate Quality control technician
Medical assistant Medical technologist/clinical Public health educator Regulatory affairs specialist
Mortician laboratory scientist Research assistant
Occupational therapist/assistant Nuclear medicine technologist Reimbursement specialist Research associate
Ophthalmic medical personnel Nutritionist (HFMA) Research scientist
Optometrist Pathologist Risk management Toxicologist
Orthotist/prosthetist Pathology assistant Social worker
Paramedic Phlebotomist Transcriptionist
Pharmacist/pharmacy technician Positron emission tomography Unit coordinator
Physical therapist/assistant (PET) technologist Utilization manager
Physician (MD/DO) Radiologic technologist/
Physician’s assistant radiographer
Psychologist
Recreation therapist
Registered nurse
Respiratory therapist
Social worker
Speech language pathologist
Surgical technician
Veterinarian/veterinary technician
Pathway Knowledge and Skills Clusters
• Academics foundation • Communications • Systems • Employability skills • Legal responsibilities • Ethics

• Safety practices Teamwork • Health maintenance practices • Technical skills • Information technology application
From National Consortium of Health Science and Technology Education, 2005.
Careers in Health Care

45
46 CHAPTER 3
To simplify the information presented in There are many health care careers in the ther-
these tables, the highest level of education for apeutic services cluster. Some of these careers are
each career group is listed. The designations used discussed in the following information sections.
are as follows:
♦ On-the-job: training while working at a job 3:2A INFORMATION
♦ HSTE program: health science technology
education program Dental Careers
♦ Associate’s degree: two-year associate’s degree Dental workers focus on the health of the teeth
♦ Bachelor’s degree: four-year bachelor’s degree and the soft tissues of the mouth. Care is directed
toward preventing dental disease, repairing or
♦ Master’s degree: one or more years beyond a
replacing diseased or damaged teeth, and treat-
bachelor’s degree to obtain a master’s degree
ing the gingiva (gums) and other supporting
♦ Doctoral (Doctor’s) degree: doctorate with four structures of the teeth.
or more years beyond a bachelor’s degree Places of employment include private dental
It is important to note that although many offices, laboratories, and clinics; or dental depart-
health careers begin with HSTE programs, obtain- ments in hospitals, schools, health departments,
ing additional education after graduation from or government agencies.
HSTE programs allows health care workers to pro- Most dental professionals work in general
gress in career level to higher-paying positions. dentistry practices where all types of dental con-
The job outlook or expected job growth ditions are treated in people of all ages. Some,
through the year 2012 is stated in the tables as however, work in specialty areas such as the fol-
“below average,” “average,” or “above average.” lowing:
Average yearly earning is presented as a range
of income, because earnings will vary according
♦ Endodontics: treatment of diseases of the
pulp, nerves, blood vessels, and roots of the
to geographical location, specialty area, level of
teeth; often called root canal treatment
education, and work experience.
All career information presented includes a ♦ Orthodontics: alignment or straightening of
basic introduction. Because requirements the teeth
for various health care careers can vary from state ♦ Oral Surgery: surgery on the teeth, mouth,
to state, it is important for students to obtain jaw and facial bones; often called maxillofa-
information pertinent to their respective states. cial surgery
More detailed information on any given career
♦ Pedodontics: dental treatment of children
discussed can be obtained from the sources listed
and adolescents
for that occupation’s career cluster.
♦ Periodontics: treatment and prevention of
diseases of the gums, bone, and structures
3:2 INFORMATION supporting the teeth
Therapeutic Services Careers ♦ Prosthodontics: replacement of natural
teeth with artificial teeth or dentures
Therapeutic careers in health care are directed
toward changing the health status of the patient Levels of workers in dentistry include dentist,
over time. dental hygienist, dental laboratory technician,
Workers in the therapeutic services use a vari- and dental assistant (see table 3-3).
ety of treatments to help patients who are injured, Dentists (DMD or DDS) are doctors who
physically or mentally disabled, or emotionally examine teeth and mouth tissues to diagnose and
disturbed. All treatment is directed toward allow- treat disease and abnormalities; perform correc-
ing patients to function at maximum capacity. tive surgery on the teeth, gums, tissues, and sup-
Places of employment include rehabilitation porting bones; and work to prevent dental
facilities, hospitals, clinics, mental health facili- disease. They also supervise the work of other
ties, daycare facilities, long-term care facilities, dental workers. Most are entrepreneurs.
home health care agencies, schools, and govern- Dental hygienists (DHs) work under the
ment agencies. supervision of dentists. They perform prelimi-
TABLE 3-3 Dental Careers

JOB OUTLOOK AVERAGE YEARLY
OCCUPATION EDUCATION REQUIRED TO YEAR 2012 EARNINGS
Dentist (DMD or DDS) • Doctor of Dental Medicine (DMD) or Below average growth $84,000–$200,000
Doctor of Dental Surgery (DDS)
• 2 or more years additional education
for specialization
• Licensure in state of practice
Dental Hygienist • Associate’s, bachelor’s, or master’s Above average growth $39,300–$83,200
(DH) degree
Licensed Dental • Licensure in state of practice
Hygienist (LDH)
Dental Laboratory • 3–4 years on-the-job or 1–2 years Average growth $23,200–$53,600
Technician (DLT) HSTE program or associate’s or
bachelor’s degree
Certified Dental • Certification can be obtained from
Laboratory National Board for Certification in
Technician (CDLT) Dental Technology
Dental Assistant • 1–3 years on-the-job or 1–2 years in
(DA) and Certified HSTE program or associate’s degree
Dental Assistant • Licensure or registration required in Above average growth $19,900–$38,700
(CDA) most states
• Certification can be obtained from
Dental Assisting National Board
nary examinations of the teeth and mouth, re- and develop radiographs, teach preventive den-
move stains and deposits from teeth, expose and tal care, sterilize instruments, and/or perform
develop radiographs, apply cavity-preventing dental receptionist duties such as scheduling
agents such as fluorides or pit and fissure appointments and handling accounts. Their
sealants to the teeth, and perform other preven- duties may be limited by the dental practice laws
tive or therapeutic (treatment) services to help of the state in which they work.
the patient develop and maintain good dental
health. In some states, dental hygienists are
authorized to place and carve restorative materi- ADDITIONAL SOURCES
als, polish restorations, remove sutures, and/or
administer anesthesia. Dental hygienists can be
OF INFORMATION
entrepreneurs. ♦ American Dental Education Association
Dental laboratory technicians (DLTs) 1400 K Street, NW
make and repair a variety of dental prostheses Washington, DC 20005
(artificial devices) such as dentures, crowns, Internet address: www.adea.org
bridges, and orthodontic appliances according to
the specifications of dentists. Specialities include ♦ American Dental Assistants Association
dental ceramist and orthodontic technician. 35 East Wacker Drive, Suite 1730
Some dental laboratory technicians are entrepre- Chicago, IL 60601-2211
neurs. Internet address: www.dentalassistant.org
Dental assistants (DAs), working under the ♦ American Dental Association
supervision of dentists, prepare patients for 211 E. Chicago Avenue
examinations, pass instruments, prepare dental Chicago, IL 60611-2678
materials for impressions and restorations, take Internet address: www.ada.org
48 CHAPTER 3
♦ American Dental Hygienists’ Association

444 N. Michigan Avenue, Suite 3400
Chicago, IL 60611
Internet address: www.adha.org
♦ Dental Assisting National Board, Inc.
676 North Saint Clair, Suite 1880
Chicago, IL 60611
Internet address: www.danb.org
♦ National Association of Dental Laboratories
325 John Knox Road
Tallahassee, FL 32303
Internet address: www.nadl.org
♦ National Association of Advisors for the Health
Professions, Inc.
FIGURE 3-3 Emergency medical technicians
P.O. Box 1518
(EMTs) provide emergency, prehospital care to
Champaign, IL 61824-1518
victims of accidents, injuries, or sudden illness.
Internet address: www.naahp.org
3-4). Another emergency medical person is a first
♦ For information about specific tasks of a den-
responder.
tal assistant, ask your instructor for the Guide-
A first responder is the first person to arrive
line for Clinical Rotations in the Diversified
at the scene of an illness or injury. Common
Health Occupations Teacher’s Resource Kit.
examples include police officers, security guards,
Additional career information is provided in
fire department personnel, and immediate fam-
the Career Highlight Section of Chapter 18 in
ily members. The first responder interviews and
this textbook.
examines the victim to identify the illness or
cause of injury, calls for emergency medical assis-
3:2B INFORMATION tance as needed, maintains safety and infection
control at the scene, and provides basic emer-
Emergency Medical Services gency medical care. A certified first responder
(CFR) course prepares individuals by teaching
Careers airway management, oxygen administration,
Emergency medical services personnel (figure bleeding control, and cardiopulmonary resusci-
3-3) provide emergency, prehospital care to vic- tation (CPR).
tims of accidents, injuries, or sudden illnesses. Emergency medical technicians basic (EMT-
Although individuals with only basic training B) provide care for a wide range of illnesses and
in first aid do sometimes work in this field, injuries including medical emergencies, bleed-
emergency medical technician (EMT) training, fractures, airway obstruction, basic life sup-
ing is required for most jobs. Formal EMT train- port (BLS), oxygen administration, emergency
ing is available in all states and is offered by childbirth, rescue of trapped persons, and trans-
fire, police, and health departments, hospitals, porting of victims.
career/technical schools, and as a nondegree Emergency medical technician defibrillator
course in technical/community colleges and (EMT-D) is a new level of EMT-B. It allows EMT-
universities. Bs with additional training and competency in
Places of employment include fire and police basic life support to administer electrical defi-
departments, rescue squads, ambulance services, brillation to certain heart attack victims.
hospital or private emergency rooms, urgent care Emergency medical technicians intermedi-
centers, industry, emergency helicopter services, ate (EMT-I) perform the same tasks as do EMT-Bs
and the military. Some EMTs are entrepreneurs. together with assessing patients, interpreting
Emergency medical technicians sometimes serve electrocardiograms (ECGs), administering defi-
as volunteers in fire and rescue departments. brillation as needed, managing shock, using
Levels of EMT include the EMT basic, EMT intravenous equipment, and inserting esopha-
intermediate, and EMT paramedic (see table geal airways.
TABLE 3-4 Emergency Medical Services Careers

EDUCATION JOB OUTLOOK AVERAGE YEARLY
OCCUPATION REQUIRED TO YEAR 2012 EARNINGS
Emergency Medical • EMT-Intermediate plus additional 6–9 months Above average $28,400–$52,600
Technician Paramedic to 2 years (over 1,000 hours) approved growth
(EMT-P)(EMT-4) paramedic training or associate’s degree
• 6 months experience as paramedic
• State certification
• Registration by the National Registry of EMTs
(NREMT) required in most states
• Other states identify as EMT-4 and administer
their own certification examination
Emergency Medical • EMT-Basic plus additional approved training Above average $21,200–$44,300
Technician of at least 35–55 hours with clinical growth
Intermediate (EMT-I) experience
(EMT-2 and EMT-3) • State certification
• Registration by the NREMT required in some
states
• Other states identify as EMT-2 and EMT-3 and
administer their own certification examination
Emergency Medical • Usually minimum 110 hours approved EMT Above average $19,200–$35,700
Technician Basic program with 10 hours of internship in growth
(EMT-B)(EMT-1) emergency room
• State certification
• Registration by National Registry of EMTs
(NREMT) required in some states
• Other states identify as EMT-1 and administer
their own certification examination
First Responder • Minimum 40 hours of approved training Above average Salary depends on
program growth individual’s regular
• Certification can be obtained from the NREMT job
Emergency medical technicians paramedic ♦ National Highway Transportation Safety

(EMT-P) perform all the basic EMT duties Administration (NHTSA)
plus in-depth patient assessment, provision of EMS Division
advanced cardiac life support (ACLS), ECG inter- 400 7th Street SW
pretation, endotracheal intubation, drug admin- Washington, DC 20590
istration, and operation of complex equipment. Internet address: www.nhtsa.dot.gov
♦ National Registry of Emergency Medical
ADDITIONAL SOURCES Technicians
6610 Busch Boulevard
OF INFORMATION P.O. Box 29233
Columbus, OH 43229
♦ National Association of Emergency Medical Internet address: www.nremt.org
Technicians
132-A East Northside Drive
P.O. Box 1400
Clinton, MS 39060-1400
Internet address: www.naemt.org
50 CHAPTER 3
♦ Doctor of Medicine (MD): Diagnoses, treats,

3:2C INFORMATION and prevents diseases or disorders; may spe-
Medical Careers cialize as noted in table 3-6
Medical careers is a broad category encompass- ♦ Doctor of Osteopathic Medicine (DO):

ing physicians (doctors) and other individuals Treats diseases/disorders, placing special
who work in any of the varied careers under the emphasis on the nervous, muscular, and
supervision of physicians. All such careers focus skeletal systems, and the relationship between
on diagnosing, treating, or preventing diseases the body, mind, and emotions; may also
and disorders of the human body. specialize
Places of employment include private prac- ♦ Doctor of Podiatric Medicine (DPM):
tices, clinics, hospitals, public health agencies, Examines, diagnoses, and treats diseases/dis-
research facilities, health maintenance organiza- orders of the feet or of the leg below the knee
tions (HMOs), government agencies, and colleges
♦ Doctor of Chiropractic (DC): Focuses on
or universities.
ensuring proper alignment of the spine and
Levels include physician, physician assistant,
optimal operation of the nervous and muscu-
and medical assistant (see table 3-5).
lar systems to maintain health
Physicians examine patients, obtain medi-
cal histories, order tests, make diagnoses, per- Physician assistants (PAs), working under
form surgery, treat diseases/disorders, and teach the supervision of physicians, take medical histo-
preventive health. Several classifications are as ries; perform routine physical examinations and
follows: basic diagnostic tests; make preliminary diagno-
TABLE 3-5 Medical Careers

Physician • Doctoral degree Above average growth $120,000–$425,500

• 3–8 years additional postgraduate training of
internship and residency depending on
specialty selected
• State licensure
• Board certification in specialty area
Physician Assistant • 2 or more years of college and usually a Above average growth $49,800–$104,600
(PA), PAC (certified) bachelor’s degree
• 2 or more years accredited physician
assistant program with certificate, associate’s,
or bachelor’s degree
• Registration, certification, or licensure
required in all states
• Certification can be obtained from National
Commission on Certification of Physician’s
Assistants
Medical Assistant • 1–2-year HSTE program or associate’s Above average growth $18,400–$46,700
(MA), CMA (certified), degree
RMA (registered) • Certification can be obtained from American
Association of Medical Assistants (AAMA)
after graduation from CAAHEP or ABHES
accredited medical assistant program
• Registered credentials can be obtained from
American Medical Technologists (AMT)
TABLE 3-6 Medical Specialties

PHYSICIAN’S TITLE SPECIALTY
Anesthesiologist Administration of medications to cause loss of sensation or feeling during surgery or

treatments
Cardiologist Diseases of the heart and blood vessels
Dermatologist Diseases of the skin
Emergency Physician Acute illness or injury
Endocrinologist Diseases of the endocrine glands
Family Physician/Practice Promote wellness, treat illness or injury in all age groups
Gastroenterologist Diseases and disorders of the stomach and intestine
Gerontologist Diseases of elderly individuals
Gynecologist Diseases of the female reproductive organs
Internist Diseases of the internal organs (lungs, heart, glands, intestines, kidneys)
Neurologist Disorders of the brain and nervous system
Obstetrician Pregnancy and childbirth
Oncologist Diagnosis and treatment of tumors (cancer)
Ophthalmologist Diseases and disorders of the eye
Orthopedist Diseases and disorders of muscles and bones
Otolaryngologist Diseases of the ear, nose, and throat
Pathologist Diagnose disease by studying changes in organs, tissues, and cells
Pediatrician Diseases and disorders of children
Physiatrist Physical medicine and rehabilitation
Plastic Surgeon Corrective surgery to repair injured or malformed body parts
Proctologist Diseases of the lower part of the large intestine
Psychiatrist Diseases and disorders of the mind
Radiologist Use of X-rays and radiation to diagnose and treat disease
Sports Medicine Prevention and treatment of injuries sustained in athletic events
Surgeon Surgery to correct deformities or treat injuries or disease
Thoracic Surgeon Surgery of the lungs, heart, or chest cavity
Urologist Diseases of the kidney, bladder, or urinary system
ses; treat minor injuries; and prescribe and

administer appropriate treatments. Pathology
assistants, working under the supervision of
pathologists, perform both gross and micro-
scopic autopsy examinations.
Medical assistants (MAs), working under
the supervision of physicians, prepare patients
for examinations; take vital signs and medical
histories; assist with procedures and treatments;
perform basic laboratory tests; prepare and main-
tain equipment and supplies; and/or perform
secretarial–receptionist duties (figure 3-4). The
type of facility and physician determines the
kinds of duties. The range of duties is determined
by state law. Assistants working for physicians
who specialize are called specialty assistants. For
example, an assistant working for a pediatrician FIGURE 3-4 Medical assistants take vital signs
is called a pediatric assistant. and prepare patients for examinations.
52 CHAPTER 3
ADDITIONAL SOURCES 3:2D INFORMATION

OF INFORMATION Mental and Social Services
Careers
♦ American Academy of Physician Assistants
Mental services professionals focus on helping
950 N. Washington Street
people with mental or emotional disorders or
Alexandria, VA 22314–1552
those who are developmentally delayed or men-
Internet address: www.aapa.org
tally impaired. Social workers help people deal
♦ American Association of Medical Assistants with illnesses, employment, or community prob-
20 N. Wacker Drive, Suite 1575 lems. Workers in both fields try to help individu-
Chicago, IL 60606–2963 als function to their maximum capacities.
Internet address: www.aama-ntl.org Places of employment include hospitals; psy-
♦ American Chiropractic Association chiatric hospitals or clinics; home health care
1701 Clarendon Boulevard agencies; public health departments; govern-
Arlington, VA 22209 ment agencies; crisis or counseling centers; drug
Internet address: www.amerchiro.org and alcohol treatment facilities; prisons; educa-
♦ American Medical Association tional institutions; and long-term care facilities.
515 North State Street Levels of employment range from psychia-
Chicago, IL 60610 trist (a physician), who diagnoses and treats men-
Internet address: www.ama-assn.org tal illness, to psychologist and psychiatric
technician. There are also various levels (includ-
♦ American Osteopathic Association ing assistant) employed in the field of social work
142 East Ontario Street (see table 3-7).
Chicago, IL 60611 Psychiatrists are physicians who specialize
Internet address: www.osteopathic.org in diagnosing and treating mental illness. Some
♦ American Podiatric Medical Association specialties include child or adolescent psychia-
9312 Old Georgetown Road try, geriatric psychiatry, and drug/chemical
Bethesda, MD 20814–1621 abuse.
Internet address: www.apma.org Psychologists study human behavior and
♦ American Society of Podiatric Medical use this knowledge to help individuals deal with
Assistants problems of everyday living. Many specialize in
2124 S. Austin Boulevard specific aspects of psychology, which include
Cicero, IL 60804 child psychology, adolescent psychology, geriat-
Internet address: www.aspma.org ric psychology, behavior modification, drug/
chemical abuse, and physical/sexual abuse.
♦ Registered Medical Assistants of the American Psychiatric/mental health technicians,
Medical Technologists working under the supervision of psychiatrists or
710 Higgins Road psychologists, help patients and their families
Park Ridge, IL 60068 follow treatment and rehabilitation plans. They
Internet address: www.amt1.org provide understanding and encouragement,
♦ For information about specific tasks of a med- assist with physical care, observe and report
ical assistant, ask your instructor for the behavior, and help teach patients constructive
Guideline for Clinical Rotations in the Diversi- social behavior. Assistants or aides who have
fied Health Occupations Teacher’s Resource Kit. completed one or more years in an HSTE pro-
Additional career information is provided in gram are also employed in this field.
the Career Highlight Section of Chapter 20 in Social workers, also called sociologists, case
this textbook. managers, or counselors (figure 3-5), aid people
TABLE 3-7 Mental and Social Services Careers

Psychiatrist • Doctoral degree Average growth $95,500–$297,000

• 2–7 years postgraduate specialty training
• State licensure
• Certification in psychiatry
Psychologist PsyD • Bachelor’s or master’s degree Above average growth $34,900–$97,800
(Doctor of • Doctor of psychology required for many or $45,900–
Psychology) positions $136,500 with
• Licensure or certification required in all doctorate
states
• Certification for specialty areas available
from American Board of Professional
Psychology
Psychiatric/Mental • Associate’s degree Average growth $28,500–$52,600
Health Technicians • Licensure required in some states
• A few states require a nursing degree
Social Workers/ • Bachelor’s or master’s degree or Doctor of Above average growth $33,500–$76,800
Sociologists Philosophy or Social Work (DSW)
• Licensure, certification or registration
required in all states
• Credentials available from National
Association of Social Workers
Genetic Counselor • Master’s degree Above average growth $38,900–$97,600
(GC) • Certification can be obtained from the
American Board on Genetic Counseling
who have difficulty coping with various problems

by helping them make adjustments in their lives
and/or by referring them to community resources
for assistance. Specialties include child welfare,
geriatrics, family, correctional (jail), and occupa-
tional social work. Many areas employ assistants
or technicians who have one or more years of an
HSTE program.
Genetic counselors provide information to
individuals and families on genetic diseases or
inherited conditions. They research the risk for
occurrence of the disease or birth defect, analyze
inheritance patterns, perform screening tests
FIGURE 3-5 Social workers help people make life for potential genetic defects, identify medical
adjustments and refer patients to community options when a genetic disease or birth defect is
resources for assistance. present, and help individuals cope with the psy-
54 CHAPTER 3
chological issues caused by genetic diseases. ♦ National Mental Health Association

Genetic counselors may specialize in prenatal 2001 N. Beauregard Street
(before birth) counseling, pediatric (child) coun- Alexandria, VA 22311
seling, neurogenetics (brain and nerves), cardio- Internet address: www.nmha.org
genetics (heart and blood vessels), or genetic
influences on cancer.
3:2E INFORMATION
ADDITIONAL SOURCES Mortuary Careers
OF INFORMATION Workers in mortuary careers provide a service
that is needed by everyone. Even though funeral
♦ American Board of Genetic Counseling practices and rites vary because of cultural diver-
9650 Rockville Pike sity and religion, most services involve prepara-
Bethesda, MD 20814 tion of the body, performance of a ceremony that
Internet address: www.abgc.net honors the deceased and meets the spiritual
needs of the living, and cremation or burial of the
♦ American Psychiatric Association remains.
1000 Wilson Boulevard, Suite 1825 Places of employment are funeral homes or
Arlington, VA 22209-3901 mortuaries, crematoriums, or cemetery associa-
Internet address: www.psych.org tions.
♦ American Psychological Association Levels include funeral director, embalmer,
750 1st Street NE and mortuary assistant (see table 3-8).
Washington, DC 20002-4242 Funeral directors, also called morticians
Internet address: www.apa.org or undertakers, provide support to the survivors;
♦ American Sociological Association interview the family of the deceased to establish
1307 New York Avenue NW, Suite 700 details of the funeral ceremonies or review
Washington, DC 20005 arrangements the deceased person requested
Internet address: www.asanet.org prior to death; prepare the body following legal
requirements; secure information for legal docu-
♦ National Mental Health Information Center ments; file death certificates; arrange and direct
P.O. Box 42557 all the details of the wake and services; make
Washington, DC 20015 arrangements for burial or cremation; and direct
Internet address: www.mentalhealth.org all business activities of the funeral home. Fre-
♦ National Association of Social Workers quently, funeral directors help surviving individ-
750 First Street NE, Suite 700 uals adapt to the death by providing post-death
Washington, DC 20002-4241 counseling and support group activities. Most
Internet address: www.naswdc.org funeral directors are also licensed embalmers.
TABLE 3-8 Mortuary Careers

Funeral Director
(Mortician) • 2–4 years in a mortuary science college or associate’s Average growth $28,600–$94,700
• Licensure required in all states except Colorado
Embalmer • 2–4 years in a mortuary science college or associate’s Average growth $22,600–$71,500
• Licensure required in all states except Colorado
Mortuary Assistant • 1–2 years on-the-job training or 1-year HSTE program Average growth $14,500–$26,800
Embalmers prepare the body for interment ♦ International Conference of Funeral Service
by washing the body with germicidal soap, replac- Examining Boards
ing the blood with embalming fluid to preserve 1885 Shelby Lane
the body, reshaping and restructuring disfigured Fayetteville, AR 72704
bodies, applying cosmetics to create a natural Internet address: www.cfseb.org
appearance, dressing the body, and placing it in a
casket. They are also responsible for maintaining
♦ National Funeral Directors Association
13625 Bishop’s Drive
embalming reports and itemized lists of clothing
Brookfield, WI 53005
or valuables.
Internet address: www.nfda.org
Mortuary assistants work under the super-
vision of the funeral director and/or embalmer.
They may assist with preparation of the body, 3:2F INFORMATION
drive the hearse to pick up the body after death or
to take it to the burial site, arrange flowers for the Nursing Careers
viewing, assist with preparations for the funeral Those in the nursing careers provide care for
service, help with filing and maintenance of patients as directed by physicians. Care focuses
records, clean the funeral home, and other simi- on the mental, emotional, and physical needs of
lar duties. the patient.
Hospitals are the major places of employ-
ment, but nursing workers are also employed in
ADDITIONAL SOURCES long-term care facilities, rehabilitation centers,
physicians’ offices, clinics, public health agencies,
OF INFORMATION home health care agencies, health maintenance
organizations (HMOs), schools, government
♦ American Board of Funeral Service Education agencies, and industry.
38 Florida Avenue Levels include registered nurse, licensed
Portland, ME 04103 practical/vocational nurse, and nurse assistant/
Internet address: www.abfse.org technician (see table 3-9).
TABLE 3-9 Nursing Careers

Registered Nurse (RN) • 2–3-year diploma program in hospital school Above average $36,500–$84,600
of nursing, or associate’s degree or bachelor’s growth
degree
• Master’s or doctoral for some administrative/ $60,300–
educational positions and for some advanced $108,900 with
practice nursing positions advanced
• Licensure in state of practice specialities
Licensed Practical/ • 1–2-year state-approved HSTE practical/ Above average $25,800–$52,600
Vocational Nurse vocational nurse program growth
(LPN/LVN) • Licensure in state of practice
Nurse Assistant • HSTE program Above average $14,900–$29,200
Geriatric Aide • Certification or registration required in all growth especially
Home Health Care states for long-term care facilities— in geriatric or
Assistant obtained by completing 75–120-hour home care
Medication Aide state-approved program
Certified Nurse Technician
Patient Care Technician
(PCT)
56 CHAPTER 3
Registered nurses (RNs) (figure 3-6), work ♦ Nurse educators: teach in HSTE programs,
under the direction of physicians and provide schools of nursing, colleges and universities,
total care to patients. The RN observes patients, wellness centers, and health care facilities
assesses patients’ needs, reports to other health
care personnel, administers prescribed medica- ♦ Nurse anesthetists: administer anesthesia,
tions and treatments, teaches health care, and monitor patients during surgery, and assist
supervises other nursing personnel. The type of anesthesiologists (who are physicians)
facility determines specific job duties. Registered ♦ Clinical nurse specialists (CNSs): use advanced
nurses with an advanced education can special- degree to specialize in specific nursing areas
ize. Examples of advanced practice nurses such as intensive care, trauma or emergency
include: care, psychiatry, pediatrics (infants and chil-
♦ Nurse practitioners (CRNPs): take health histo- dren), neonatology (premature infants), and
ries, perform basic physical examinations, gerontology (elderly individuals)
order laboratory tests and other procedures,
Licensed practical/vocational nurses
refer patients to physicians, help establish
(LPNs/LVNs), working under the supervision of
treatment plans, treat common illnesses such
physicians or RNs, provide patient care requiring
as colds or sore throats, and teach and pro-
technical knowledge but not the level of educa-
mote optimal health
tion required of RNs. The type of care is deter-
♦ Nurse midwives (CNMs): provide total care for mined by the work environment, which can
normal pregnancies, examine the pregnant include the home, hospital, long-term care facil-
woman at regular intervals, perform routine ity, adult daycare center, physician’s office, clinic,
tests, teach childbirth and childcare classes, wellness center, and health maintenance organi-
monitor the infant and mother during child- zation. Care provided by LPN/LVNs is also deter-
birth, deliver the infant, and refer any prob- mined by state laws regulating the extent of
lems to a physician duties.
Nurse assistants (also called nurse aides,
nurse technicians, patient care technicians
(PCTs), or orderlies) work under the supervision
of RNs or LPNs/LVNs. They provide patient care
such as baths, bedmaking, and feeding; assist in
transfer and ambulation; and administer basic
treatments. Geriatric aides/assistants acquire
additional education to provide care for the
elderly in work environments such as extended
care facilities, nursing homes, retirement centers,
adult daycare agencies, and other similar agen-
cies. Home health care assistants are trained
to work in the patient’s home and may perform
additional duties such as meal preparation or
cleaning. Medication aides/assistants receive
special training such as a 40-hour or more state-
approved medication aide course to administer
medications to patients or residents in long-term
care facilities or patients receiving home health
care. Most states that have the medication aide
program require that the aide be on the state-
approved list for nurse or geriatric assistants
before taking the medication aide course. In addi-
tion, many states require a competency test.
Each nursing assistant working in a long-
FIGURE 3-6 Registered nurses (RNs) administer term care facility or home health care is now
prescribed medications to patients. required under federal law to complete a manda-
tory, state-approved training program and pass a

written and/or competency examination to 3:2G INFORMATION
obtain certification or registration. Health work-
ers in these environments should check the
Nutrition and Dietary Services
requirements of their respective states. Careers
Health, nutrition, and physical fitness have
become a way of life. Workers employed in the
nutrition and dietary services recognize the
ADDITIONAL SOURCES importance of proper nutrition to good health.
OF INFORMATION Using knowledge of nutrition, they promote well-
ness and optimum health by providing dietary
guidelines used to treat various diseases, teach-
♦ American College of Nurse Practitioners ing proper nutrition, and preparing foods for
1111 19th Street NW, Suite 404
health care facilities.
Washington, DC 20036
Places of employment include hospitals,
Internet address: www.acnpweb.org
long-term care facilities, child and adult daycare
♦ American Health Care Association facilities, wellness centers, schools, home health
1201 L Street NW care agencies, public health agencies, clinics,
Washington, DC 20005 industry, and offices.
Internet address: www.ahca.org Levels include dietitian, dietetic technician,
♦ American Nurses’ Association and dietetic assistant (see table 3-10).
8515 Georgia Avenue, Suite 400 Dietitians (RDs) or nutritionists (figure 3-7)
Silver Spring, MD 20910 manage food service systems, assess patients’/
Internet address: www.nursingworld.org residents’ nutritional needs, plan menus, teach
others proper nutrition and special diets, research
♦ National Association for Home Care and
nutrition needs and develop recommendations
Hospice
based on the research, purchase food and equip-
228 Seventh Street SE
Internet address: www.nahc.org
♦ National Association for Practical Nurse
Education and Service
P.O. Box 25647
Alexandria, VA 22313
Internet address: www.napnes.org
♦ National Federation of Licensed Practical
Nurses
605 Poole Drive
Garner, NC 27529
Internet address: www.nflpn.org
♦ National League for Nursing
61 Broadway
New York, NY 10006
Internet address: www.nln.org
♦ For information about specific tasks of a geri-
atric assistant/technician or nurse assistant/
technician, ask your instructor for the Guide-
line for Clinical Rotations in the Diversified
Health Occupations Teacher’s Resource Kit.
Additional career information is provided in FIGURE 3-7 Dietitians manage food service
the Career Highlight Section of Chapter 21 in systems, assess nutritional needs, and plan menus
this textbook. according to prescribed diets.
58 CHAPTER 3
TABLE 3-10 Nutrition and Dietary Services Careers

Dietitian, RD • Bachelor’s or master’s degree Average growth $32,700–$68,300

(registered) • Registration can be obtained from Commission on
Dietetic Registration of the American Dietetic
Association
• Licensure, certification, or registration required in
many states
Dietetic Technician, • Associate’s degree Average growth $24,200–$49,200
DTR (registered) • Licensure, certification, or registration required in
some states
• Registration can be obtained from the Commission on
Dietetic Registration
Dietetic Assistant • 6–12 months on the job Average growth $13,600–$24,900
• One or more years HSTE or food service career/
technical program
ment, enforce sanitary and safety rules, and Chicago, IL 60607

supervise and/or train other personnel. Some Internet address: www.ift.org
dietitians specialize in the care of pediatric
(child), renal (kidney), or diabetic patients, or in
♦ For information about specific tasks of a
dietary assistant/food service worker, ask your
weight management.
instructor for the Guideline for Clinical Rota-
Dietetic technicians (DTs), working under
tions in the Diversified Health Occupations
the supervision of dietitians, plan menus, order
Teacher’s Resource Kit.
foods, standardize and test recipes, assist with
food preparation, provide basic dietary instruc-
tion, and teach classes on proper nutrition. 3:2H INFORMATION
Dietetic assistants, also called food service
workers, work under the supervision of dietitians Veterinary Careers
and assist with food preparation and service, help Veterinary careers focus on providing care to all
patients select menus, clean work areas, and types of animals—from house pets to livestock to
assist other dietary workers. wildlife.
Places of employment include animal hospi-
ADDITIONAL SOURCES tals, veterinarian offices, laboratories, zoos, farms,

animal shelters, aquariums, drug or animal food
OF INFORMATION companies; and fish and wildlife services.
Levels of employment include veterinarian,
♦ American Dietetic Association animal health technician, and assistant (see table
120 South Riverside Plaza, Suite 2000 3-11).
Chicago, IL 60606-6995 Veterinarians (DVMs or VMDs) (figure 3-8)
Internet address: www.eatright.org work to prevent, diagnose, and treat diseases and
injuries in animals. Specialties include surgery,
♦ Dietary Managers Association small-animal care, livestock, fish and wildlife,
406 Surrey Woods Drive and research.
St. Charles, IL 60174 Veterinary technologists/technicians
Internet address: www.dmaonline.org (VTs), also called animal health technicians, work-
♦ Institute of Food Technologists ing under the supervision of veterinarians, assist
525 West Van Buren, Suite 1000 with the handling and care of animals, collect
TABLE 3-11 Veterinary Careers

Veterinarian • 3–4 years preveterinary college Above average $45,300–$125,900

(DVM or VMD) • 4 years veterinary college and Doctor of growth
Veterinary Medicine degree
• State licensure required in all states
Veterinary • Associate’s degree for veterinary technician Above average $20,200–$61,800
(Animal Health) • Bachelor’s degree for veterinary technologist growth
Technologist/Technician • Registration, certification, or licensure required in
VTR (registered) most states
• Certification for technologists/technicians
employed in animal laboratory research facilities
can be obtained from the American Association for
Laboratory Animal Science (AALAS)
Veterinary Assistant • 1–2 years on the job or 1–2-year HSTE program Above average $15,200–$35,300
(Animal Caretakers) growth
specimens, assist with surgery, perform laboratory

tests, take and develop radiographs, administer
prescribed treatments, and maintain records.
Veterinary assistants, also called animal
caretakers, feed, bathe, and groom animals; exer-
cise animals; prepare animals for treatment;
assist with examinations; clean and sanitize
cages, examination tables, and surgical areas;
and maintain records.
ADDITIONAL SOURCES
OF INFORMATION
♦ American Association for Laboratory
Animal Science
9190 Crestwyn Hills Drive
Memphis, TN 38125
Internet address: www.aalas.org
♦ American Veterinary Medical Association
1931 N. Meacham Road, Suite 100
Schaumburg, IL 60173-4360
Internet address: www.avma.org
♦ Animal Caretakers Information
The Humane Society of the United States FIGURE 3-8 Veterinarians work to prevent,
2100 L Street NW diagnose, and treat diseases and injuries in ani-
Washington, DC 20037 mals. (Courtesy Warren, Small Animal Care and
Internet address: www.hsus.org Management, 1995, Delmar Learning)
60 CHAPTER 3
♦ North America Veterinary Technician Associa- stores, hospitals, schools, health maintenance
tion (NAVTA) organizations (HMOs), government agencies,
P. O. Box 224 and clinics.
Battle Ground, IN 47920 Levels include ophthalmologist, optometrist,
Internet address: www.navta.net ophthalmic medical technologist, ophthalmic
technician, opthalmic assistant, optician, and
♦ For information about specific tasks of a vet- ophthalmic laboratory technician (see table 3-12).
erinary assistant, ask your instructor for the
Many individuals in this field are entrepreneurs.
Guideline for Clinical Rotations in the Diversi-
Ophthalmologists are medical doctors
fied Health Occupations Teacher’s Resource
specializing in diseases, disorders, and injuries of
Kit.
the eyes. They diagnose and treat disease, per-
form surgery, and correct vision problems or
3:2I INFORMATION defects.
Optometrists (ODs), doctors of optometry,
Vision Services Careers examine eyes for vision problems and defects,
Workers in the vision services provide care to pre- prescribe corrective lenses or eye exercises, and
vent and treat vision disorders. Places of employ- in some states, use drugs for diagnosis and/or
ment include offices, optical shops, department treatment. If eye disease is present or if eye sur-
TABLE 3-12 Vision Services Careers

Opthalmologist • Doctoral degree Average growth $108,000–$248,500

(MD) • 2–7 years postgraduate specialty training
• State licensure
• Certification in ophthalmology
Optometrist (OD) • 3–4 years preoptometric college Average growth $62,300–$125,300
• Four years at college of optometry for doctor of
optometry degree
• State licensure
Ophthalmic Medical • Associate’s or bachelor’s degree Average growth $28,600–$68,500
Technologist • Certification can be obtained from the Joint
COMT (certified) Commission on Allied Health Personnel in
Ophthalmology (JCAHPO)
Ophthalmic Technician • Associate’s degree Average growth $27,500–50,200
COT (certified) • Certification can be obtained from JCAHPO
Ophthalmic Assistant • Some on-the-job training Average growth $14,900–31,500
COA (certified) • One month to 1-year HSTE program
• Certification can be obtained from the JCAHPO
Optician • 2–4 years on the job or 2–4-year apprenticeship Average growth $19,400–$46,500
or HSTE program or associate’s degree
• Licensure or certification required in some states
• Certification can be obtained from Amercian
Board of Opticianry and National Contact Lens
Examiners
Ophthalmic • 2–3 years on the job or 1-year HSTE certificate Below average $15,400–$35,600
Laboratory program growth
Technician
gery is needed, the optometrist refers the patient Opticians make and fit the eyeglasses or
to an ophthalmologist. lenses prescribed by ophthalmologists and
Ophthalmic medical technologists optometrists. Some specialize in contact lenses.
(OMTs), working under the supervision of opthal- Ophthalmic laboratory technicians cut,
mologists, obtain patient histories, perform rou- grind, finish, polish, and mount the lenses used
tine eye tests and measurements, fit patients for in eyeglasses, contact lenses, and other optical
contacts, administer prescribed treatments, instruments such as telescopes and binoculars.
assist with eye surgery, perform advanced diag-
nostic tests such as ocular motility and biocular
function tests, administer prescribed medica- ADDITIONAL SOURCES
tions, and perform advanced microbiological
procedures. In addition, they may perform any OF INFORMATION
tasks that ophthalmic technicians or assistants
perform. ♦ American Optometric Association
Ophthalmic technicians (OTs) (figure 3-9) 243 N. Lindbergh Boulevard
work under the supervision of ophthalmologists St. Louis, MO 63141
and optometrists. Technicians prepare patients Internet address: www.aoanet.org
for examinations, obtain medical histories, take ♦ Association of Schools and Colleges of
ocular measurements, administer basic vision Optometry
tests, maintain ophthalmic and surgical instru- 6110 Executive Boulevard, Suite 510
ments, adjust glasses, teach eye exercises, measure Rockville, MD 20852
for contacts, instruct patients on the care and use Internet address: www.opted.org
of contacts, and perform receptionist duties. ♦ Commission on Opticianry Accreditation
Ophthalmic assistants (OAs) work under 8665 Sudley Road, Suite 341
the supervision of ophthalmologists, optome- Manassas, VA 20110
trists, and/or ophthalmic medical technologists Internet address: www.coaccreditation.com
or technicians. Assistants prepare patients for
examinations, measure visual acuity, perform ♦ Joint Commission on Allied Health Personnel
receptionist duties, help patients with frame in Ophthalmology
selections and fittings, order lenses, perform 2025 Woodlane Drive
minor adjustments and repairs of glasses, and St. Paul, MN 55125-2995
teach proper care and use of contact lenses. Internet address: www.jcahpo.org
♦ National Federation of Opticianry Schools
1238 Robinson Point Road
Mountain Home, AR 72653
Internet address: ww.nfos.org
♦ Opticians Association of America
441 Carlisle Drive
Herndon, VA 20170
Internet address: www.oaa.org
3:2J INFORMATION
Other Therapeutic Services
Careers
There are many other therapeutic service careers.
Some are discussed in this section. Most thera-
FIGURE 3-9 Ophthalmic technicians perform peutic occupations include levels of therapist,
basic vision tests and teach eye exercises. (Cour- technician, and assistant/aide (see table 3-13).
tesy of the American Optometric Association, St. Occupational therapists (OTs) (figure
Louis, MO) 3-10) often work under the direction of a physia-
62 CHAPTER 3
TABLE 3-13 Other Therapeutic Services Careers

Occupational Therapist • Master’s degree and internship Above average

(OT) OTR (registered) • Licensure required in all states growth $43,900–$93,600
• Certification can be obtained from American
Occupational Therapy Association
Occupational Therapy • Associate’s degree or certificate and internship Above average $32,500–$56,600
Assistant • Licensure or certification required by most states growth
COTA (certified) • Certification can be obtained from American
Occupational Therapy Association
Pharmacist • 5–6-year college program with Doctor of Above average $56,800–$103,500
(PharmD) Pharmacy degree plus internship growth
• Licensure required in all states
Pharmacy • 1 or more years on the job or 1–2-year HSTE Above average $17,300–$36,400
Technician program or associate’s degree growth
• Licensure required in many states
• Certification can be obtained from the Pharmacy
Technician Certification Board
Physical Therapist • Master’s or doctoral degree Above average $48,400–$108,300
(PT) • Licensure required in all states growth
Physical Therapist • Associate’s degree plus internship Above average $23,500–$54,900
Assistant (PTA) • Licensure required in most states growth
Massage Therapist • 3-month to 1-year accredited Massage Therapy Above average $22,400–$46,500
Program growth
• Certification, registration, or licensure required in
many states
• Certification can be obtained from the National
Certification Board for Therapeutic Massage and
Bodywork (NCBTMB)
Recreational Therapist • Possibly associate’s but usually bachelor’s degree Average growth $26,800–$54,500
(TR) plus internship
Certified Therapeutic • Licensure or certification required in a few states
Recreation Specialist • Certification can be obtained from National
(CTRS) Council for Therapeutic Recreation Certification
(NCTRC)
• Registration can be obtained from Association for
Rehabilitation Therapy
Recreational Therapist • 1–2-year HSTE certificate program or associate’s Average growth $14,700–$32,800
Assistant (Activity degree
Director) • Certification can be obtained from National
Council for Therapeutic Recreation Certification
Respiratory Therapist, • Associate’s or bachelor’s degree Above average $32,800–$66,300
RTRRT (registered) • Licensure required in most states growth
• Registration can be obtained from National Board
for Respiratory Care
Respiratory Therapy • 1–2-year HSTE program or associate’s degree Above average $23,400–$49,800
Technician (RTT) • Licensure or certification required in most states growth
CRTT (certified) • Certification can be obtained from National Board
for Respiratory Care
(continued)
TABLE 3-13 Other Therapeutic Services Careers (Continued)
Speech–Language • Master’s degree and 9 months postgraduate Above average $40,100–$82,500

Therapist/Pathologist clinical experience growth
and/or Audiologist • Licensure required in most states
• Clinical doctoral degree common for audiologists
• Audiologists may obtain certification from the
American Board of Audiology
• Certificate of Clinical Competence in Speech–
Language Pathology (CCC–SLP) or Audiology
(CCC–A) can be obtained from American
Speech-Language-Hearing Association (ASHA)
Surgical Technician/ • 1–2-year HSTE program Above average $24,800–$48,500
Technologist • Certificate, diploma, or associate’s degree growth
CST (certified) • Certification can be obtained from Liaison
Council on Certification for Surgical
Technologists
Art, Music, Dance • Bachelor’s or master’s degree Average growth $25,700–$64,500
Therapist • Certification for art therapist can be obtained
from American Art Therapy Association
• Registration for music therapist can be obtained
from National Association of Music Therapy
and American Association for Music Therapy
• Registration for dance therapist (DTR) can be
obtained from American Dance Therapy
Association
• Registration for art therapist (ATR) can be
obtained from the Art Therapy Credentials Board
Athletic Trainer ATC • Bachelor’s or master’s degree Above average $35,000–$73,800
(certified) • Licensure required in some states growth
• Most states require certification
Athletic Trainers Association
Dialysis Technician • Varies with states Average growth $18,700–$56,800
• Some states require RN or LPN license and
state-approved dialysis training
• Other states require 1–2-year HSTE state-
approved dialysis program or associate’s degree
Association of Nephrology Technicians/
Technologists
Perfusionist • Bachelor’s degree Above average $51,600–$112,800
Certified Clinical • Specialized extracorporeal circulation training growth
Perfusionist (CCP) and supervised clinical experience
Extracorporeal • Licensure required in some states
Circulation • Certification can be obtained from American
Technologist Board of Cardiovascular Perfusion
64 CHAPTER 3
FIGURE 3-11 Pharmacists dispense medications

and provide information on drugs. (Courtesy of the
FIGURE 3-10 Occupational therapists (OTs) help Michigan Pharmacists Association and the Michigan
patients with disabilities to overcome, correct, or Society of Pharmacy Technicians)
adjust to the disabilities.
trist, a physician specializing in physical medi- fessionals authorized to prescribe medications.

cine and rehabilitation. OTs help people with They provide information on drugs and correct
physical, developmental, mental, or emotional ways to use them; order and dispense other
disabilities to overcome, correct, or adjust to their health care items such as surgical and sickroom
particular problems. The occupational therapist supplies; recommend nonprescription items to
uses various activities to assist the patient in customers/patients; ensure drug compatibility;
learning skills or activities of daily living (ADL), maintain records on medications dispensed; and
adapting job skills, or preparing for return to assess, plan, and monitor drug usage. Pharma-
work. Treatment is directed toward helping cists can also either be entrepreneurs or work for
patients acquire independence, regain lost func- one of the many drug manufacturers involved in
tions, adapt to disabilities, and lead productive researching, manufacturing, and selling drugs.
and satisfying lives. Pharmacy technicians, working under the
Occupational therapy assistants (OTAs), supervision of pharmacists, help prepare medi-
working under the guidance of occupational cations for dispensing to patients, label medica-
therapists, help patients carry out programs of tions, perform inventories and order supplies,
prescribed treatment. They direct patients in arts prepare intravenous solutions, help maintain
and crafts projects, recreation, or social events; records, and perform other duties as directed by
teach and help patients carry out rehabilitation pharmacists.
activities and exercises; use games to develop Physical therapists (PTs) (figure 3-12)
balance and coordination; assist patients trying often work under the direction of a physiatrist, a
to master the activities of daily living; and inform physician specializing in physical medicine and
therapists of patients’ responses and progress. rehabilitation. PTs provide treatment to improve
Pharmacists (PharmDs) (figure 3-11) dis- mobility and prevent or limit permanent disabil-
pense medications per written orders from ity of patients with disabling joint, bone, muscle,
physicians, dentists, and other health care pro- and/or nerve injuries or diseases. Treatment may
or inflammatory diseases, improve lymphatic

circulation to decrease edema (swelling), and
relieve stress and tension. Some massage thera-
pists are entrepreneurs.
Recreational therapists (TRs), or thera-
peutic recreation specialists, use recreational and
leisure activities as forms of treatment to mini-
mize patients’ symptoms and improve physical,
emotional, and mental well-being. Activities
might include organized athletic events, dances,
arts and crafts, musical activities, drama, field
trips to shopping centers or other places of inter-
est, movies, or poetry or book readings. All activi-
ties are directed toward allowing the patient to
gain independence, build self-confidence, and
relieve anxiety. Some recreational therapists are
entrepreneurs.
Recreational therapy assistants, also
called activity directors, work under the supervi-
sion of recreational therapists or other health
care professionals. They assist in carrying out the
activities planned by therapists and, at times,
FIGURE 3-12 Physical therapists (PTs) provide arrange activities or events. They note and inform
treatment to improve mobility of patients with therapists of patients’ responses and progress.
disabling injuries or diseases. Respiratory therapists (RTs), under phy-
sicians’ orders, treat patients with heart and lung
diseases by administering oxygen, gases, or med-
include exercise, massage, and/or applications of ications; using exercise to improve breathing;
heat, cold, water, light, electricity, or ultrasound. monitoring ventilators; and performing diagnos-
Therapists assess the functional abilities of tic respiratory function tests (figure 3-13). Some
patients and use this information to plan treat- respiratory therapists are entrepreneurs.
ment programs. They also promote health and Respiratory therapy technicians (RTTs)
prevent injuries by developing proper exercise work under the supervision of respiratory thera-
programs and teaching patients correct use of pists and administer respiratory treatments, per-
muscles. Some physical therapists are entrepre- form basic diagnostic tests, clean and maintain
neurs.
Physical therapist assistants (PTAs),
working under the supervision of physical thera-
pists, help carry out prescribed plans of treat-
ment. They perform exercises and massages;
administer applications of heat, cold, and/or
water; assist patients to ambulate with canes,
crutches, or braces; provide ultrasound or elec-
trical stimulation treatments; inform therapists
of patients’ responses and progress; and perform
other duties, as directed by therapists.
Massage therapists usually work under the
supervision of physicians or physical therapists.
They use many variations of massage, bodywork
(manipulation or application of pressure to the
muscular or skeletal structure of the body), and FIGURE 3-13 Respiratory therapists (RTs)
therapeutic touch to muscles to provide pain provide treatments to patients with heart and lung
relief for chronic conditions (such as back pain) diseases.
66 CHAPTER 3
equipment, and note and inform therapists of Athletic trainers (ATCs) prevent and treat
patients’ responses and progress. athletic injuries and provide rehabilitative ser-
Surgical technologists/technicians (STs), vices to athletes. The athletic trainer frequently
also called operating room technicians (figure works with a physician who specializes in sports
3-14), working under the supervision of RNs or medicine. Athletic trainers teach proper nutri-
physicians, prepare patients for surgery; set up tion, assess the physical condition of athletes,
instruments, equipment, and sterile supplies in give advice regarding a physical conditioning
the operating room; and assist during surgery by program to increase strength and flexibility or
passing instruments and supplies to the surgeon. correct weaknesses, put tape or padding on play-
Although most surgical technologists/techni- ers to protect body parts, treat minor injuries,
cians work in hospital operating rooms, some are administer first aid for serious injuries, and help
employed in outpatient surgical centers, emer- carry out any rehabilitation treatment prescribed
gency departments, urgent care centers, physi- by sports medicine physicians or other thera-
cians’ offices, and other facilities. pists.
Speech–language pathologists, also Dialysis technicians, also called renal dial-
called speech therapists or speech scientists, iden- ysis technicians, hemodialysis technicians, or
tify, evaluate, and treat patients with speech and nephrology technicians, operate the kidney
language disorders. They help patients commu- hemodialysis machines used to treat patients
nicate as effectively as possible, and also teach with limited or no kidney function. Careful
patients to cope with the problems created by patient monitoring is critical during the dialysis
speech impairments. process. The dialysis technician must also pro-
Audiologists provide care to individuals vide emotional support for the patient and teach
who have hearing impairments. They test hear- proper nutrition (because many patients must
ing, diagnose problems, and prescribe treatment, follow restricted diets).
which may include hearing aids, auditory train- Perfusionists, also called extracorporeal
ing, or instruction in speech or lip reading. They circulation technologists, are members of open-
also test noise levels in workplaces and develop heart surgical teams and operate the heart–lung
hearing protection programs. machines used in coronary bypass surgery (sur-
Art, music, and dance therapists use the gery on the coronary arteries in the heart). This
arts to help patients deal with social, physical, or field is expanding to include new advances such
emotional problems. Therapists usually work as artificial hearts. Monitoring and operating
with individuals who are emotionally disturbed, these machines correctly is critical because the
mentally retarded, or physically disabled, but patient’s life depends on the machines. During
they may also work with adults and children who surgery, the perfusionist monitors blood gases
have no disabilities in an effort to promote physi- and vital signs; administers blood products, anes-
cal and mental wellness. thetic agents, and/or drugs as needed; and
induces hypothermia (low body temperature) to
decrease the body’s need for oxygen. After the
surgery, the perfusionist must restore normal
body circulation when the heart starts beating
and wean the patient from the extracorporeal
machine.
ADDITIONAL SOURCES
OF INFORMATION
♦ American Alliance for Health, Physical Educa-
tion, Recreation, and Dance
1900 Association Drive
FIGURE 3-14 Surgical technologists assist by Reston, VA 22091-1598
passing instruments and supplies to the surgeon. Internet address: www.aahperd.org
♦ American Art Therapy Association ♦ American Speech-Language-Hearing

1202 Allanson Road Association
Mundelheim, IL 60060-3808 10801 Rockville Pike
Internet address: www.arttherapy.org Rockville, MD 20852
Internet address: www.asha.org
♦ American Academy of Audiology
11730 Plaza America Drive, Suite 300 ♦ American Therapeutic Recreation Association
Reston, VA 20190 1414 Prince Street, Suite 204
Internet address: www.audiology.org Alexandria, VA 22314
Internet address: www.atra-tr.org
♦ American Association for Respiratory Care
9425 N. MacArthur Boulevard, Suite 100
♦ Associated Bodywork and Massage
Professionals
Irving, TX 75063-48706
1271 Sugarbush Drive
Internet address: www.aarc.org
Evergreen, CO 80439-9766
♦ American Association of Colleges of Internet address: www.abmp.com
Pharmacy ♦ Association of Surgical Technologists
1426 Prince Street 6 W. Dry Creek Circle
Alexandria, VA 22314 Littleton, CO 80120
Internet address: www.aacp.org Internet address: www.ast.org
♦ American Dance Therapy Association ♦ Massage and Bodywork Resource Center
10632 Little Patuxent Parkway Internet address: www.massageresource.com
Columbia, MD 21044 ♦ National Athletic Trainers Association
Internet address: www.adta.org 2952 Stemmons Freeway
♦ American Massage Therapy Association Dallas, TX 75247
820 Davis Street, Suite 100 Internet address: www.nata.org
Evanston, IL 60201-4444 ♦ National Therapeutic Recreation Society
Internet address: www.amtamassage.org 22377 Belmont Ridge Road
Ashburn, VA 20148
♦ American Music Therapy Association
Internet address: www.nrpa.org
8455 Colesville Road
Silver Spring, MD 20910 ♦ Pharmacy Technician Certification Board
Internet address: www.musictherapy.org 2215 Constitution Avenue NW
Washington, DC 20037-2985
♦ American Pharmacists Association Internet address: www.ptcb.org
2215 Constitution Avenue NW
Washington, DC 20037-2985 ♦ For information about specific tasks of a phar-
Internet address: www.aphanet.org macy technician/assistant, physical therapy
assistant/technician, or respiratory therapy
♦ American Physical Therapy Association assistant/technician, ask your instructor for
1111 N. Fairfax Street the Guideline for Clinical Rotations in the
Alexandria, VA 22314-1488 Diversified Health Occupations Teacher’s
Internet address: www.apta.org Resource Kit. Additional career information for
physical therapy is provided in the Career High-
♦ American Occupational Therapy Association light Section of Chapter 22 in this textbook.
4720 Montgomery Lane, P. O. Box 31220
Bethesda, MD 20824-1220
Internet address: www.aota.org
3:3 INFORMATION
♦ American Society of Extracorporeal Technolo-
gists Diagnostic Services Careers
2209 Dickens Road Diagnostic service workers are involved with cre-
P.O. Box 11086 ating a picture of the health status of a patient at
Richmond, VA 23230-1086 a single point in time. They perform tests or eval-
Internet address: www.amsect.org uations that aid in the detection, diagnosis, and
68 CHAPTER 3
treatment of disease, injury, or other physical Many careers fall under the designation of
conditions. diagnostic services. Some of the more common
Many workers are employed in hospital labo- ones are discussed in this chapter. There are vari-
ratories, but others work in private laboratories, ous levels of workers in most fields (table 3-14).
outpatient centers, doctors’ offices, clinics, pub- Electrocardiograph (ECG) technicians
lic health agencies, pharmaceutical (drug) firms, operate electrocardiograph machines, which
and research or government agencies. In some record electrical impulses that originate in the
occupations, individuals are entrepreneurs, own- heart. Physicians (especially cardiologists) use
ing and operating their own businesses. the electrocardiogram (ECG) to help diagnose
TABLE 3-14 Diagnostic Services Careers

Cardiovascular • Associate’s or bachelor’s degree Above average $27,500–$58,600

Technologist • Certification or registration can be obtained from growth
Cardiovascular Credentialing International
Registered Diagnostic • Registration can be obtained from the American
Vascular Technologist Registry of Diagnostic Medical Sonographers
(RDVT)
Electrocardiograph • 1–12 months on-the-job or 6–12-month-HSTE Below average $17,300–$32,800
(ECG Technician) program growth
Certified • Certification can be obtained from Cardiovascular
Cardiographic Credentialing International
Technician (CCT)
Electroencephalo- • Few have 1–2-years on-the-job Below average $22,300–$46,200
graphic (EEG) • Most have 1–2-year HSTE certification program or growth
Technologist associate’s degree
• Registration can be obtained from American Board of
Registration of Electroencephalographic and Evoked
Potential Technologists
Electroneurodiagnostic • 1–2-year program usually leading to associate’s Above average $35,800–$56,200
Technologist degree growth
• Registration can be obtained from the American
Board of Electroencephalographic and Evoked
Potential Technologists
• Polysomnographic technologists can obtain
registration from the Association of
Polysomnographic Technologists
Medical (Clinical) • Bachelor’s or master’s degree Average growth $35,800–$66,900
Laboratory • Licensure or registration required in some states
Technologist (MT) • Certification can be obtained from the American
Certified Medical Medical Technologists Association and the National
(Clinical) Laboratory Credentialing Agency for Laboratory Personnel
Technologist (CMT)
Registered Medical
(Clinical) Laboratory
Technologist (RMT)
(continued)
TABLE 3-14 Diagnostic Services Careers (Continued)

Medical (Clinical) • 2-year HSTE certification program or associate’s Average growth $26,300–$48,900
Laboratory Technician degree
(MLT) • Licensure or registration required in some states
Certified Laboratory • Certification can be obtained from the American
Technician (CLT) Medical Technologists Association and the National
Credentialing Agency for Laboratory Personnel
Medical (Clinical) • 1–2-year HSTE program or on-the-job training Below average $14,500–$26,300
Laboratory Assistant • Certification can be obtained from the Board of growth
Certified Laboratory Assistants
Phlebotomist • 1–2 years on the job or HSTE program or 100–300 Average growth $14,600–$28,300
hour certification program
• Certification can be obtained from the National
Credentialing Agency for Laboratory Personnel and
the American Society of Phlebotomy Technicians
Radiologic • Associate’s or bachelor’s degree Above average $28,900–$68,600
Technologist ARRT • Licensure required in most states growth
(Registered) • Registration can be obtained from American Registry
of Radiologic Technologies (ARRT)
heart disease and to note changes in the condi- An electroencephalographic (EEG) tech-
tion of a patient’s heart. ECG or cardiographic nologist operates an instrument called an elec-
technicians with more advanced training perform troencephalograph, which records the electrical
stress tests (which record the action of the heart activity of the brain. The record produced, called
during physical activity), Holter monitorings an electroencephalogram, is used by a variety of
(ECGs lasting 24–48 hours, figure 3-15), thallium physicians, especially neurologists (doctors spe-
scans (a nuclear scan after thallium is injected), cializing in nerve and brain diseases), to diagnose
and other specialized cardiac tests that frequently and evaluate diseases and disorders of the brain,
involve the use of computers. An associate’s or such as brain tumors, strokes, toxic/metabolic
bachelor’s degree leads to a position as a cardio- disorders, epilepsy, and sleep disorders. Advanced
vascular technologist. These individuals assist training leads to a position as an electroneuro-
with cardiac catheterization procedures and diagnostic technologist (END). In addition to
angioplasty (a procedure to remove blockages in performing EEGs, these individuals perform
blood vessels), monitor patients during open- nerve conduction tests, measure sensory and
heart surgery and the implantation of pacemak- physical responses to specific stimuli, perform
ers, and perform tests to check circulation in evoked potential (EP) tests that measure brain
blood vessels. Some specialize in using ultra- response when specific nerves are stimulated,
sound (high-frequency sound waves) to assess and operate other monitoring devices. Technolo-
heart function and diagnose heart conditions gists who specialize in administering sleep disor-
and are called echocardiographers or cardiac der evaluations are called polysomnographic
sonographers. Others use ultrasound to diagnose technologists.
disorders of blood vessels by checking blood Medical (clinical) laboratory technolo-
pressure, oxygen saturation, and circulation of gists (MTs) work under the supervision of doc-
blood throughout the body. They are called vas- tors called pathologists. They study tissues, fluids,
cular technologists or vascular sonographers. and cells of the human body to help determine
70 CHAPTER 3
FIGURE 3-16 Medical laboratory technologists

perform computerized blood analysis tests. (Photo
by Marcia Butterfield, courtesy of W. A. Foote
Memorial Hospital, Jackson, MI)
♦ Microbiology: study of bacteria and other

microorganisms
Medical (clinical) laboratory techni-
cians (MLTs), working under the supervision of
medical technologists or pathologists, perform
many of the routine tests that do not require the
advanced knowledge held by a medical technolo-
FIGURE 3-15 Cardiographic technicians assist gist. Like the technologist, the technician can
with Holter monitorings of the heart. specialize in a particular field or perform a vari-
ety of tests.
Medical (clinical) laboratory assistants,
working under the supervision of medical tech-
the presence and/or cause of disease. They per- nologists, technicians, or pathologists, perform
form complicated chemical, microscopic, and basic laboratory tests; prepare specimens for
automated analyzer/computer tests (figure 3-16). examination or testing; and perform other labo-
In small laboratories, technologists perform ratory duties such as cleaning and helping to
many types of tests. In larger laboratories, they maintain equipment.
may specialize. Examples of specialization Phlebotomists (figure 3-17), or venipunc-
include: ture technicians, collect blood and prepare it for
♦ Biochemistry: chemical analysis of body testing. In some states, they perform blood tests
fluids under the supervision of medical technologists
or pathologists.
♦ Blood bank technology: collection and prepa- Radiologic technologists (RTs), working
ration of blood and blood products for trans- under the supervision of doctors called radiolo-
fusions gists, use X-rays, radiation, nuclear medicine,
♦ Cytotechnology: study of human body cells ultrasound, and magnetic resonance to diagnose
and cellular abnormalities and treat disease. Most techniques are noninva-
♦ Hematology: study of blood cells sive, which means examining or treating the
internal organs of patients without entering the
♦ Histology: study of human body tissue body. In many cases, recent advances in this field
♦ Molecular biology: complex protein and have eliminated the need for surgery and, there-
nucleic acid testing on cell samples fore, offer less risk to patients. Radiologic tech-
FIGURE 3-17 Phlebotomists collect blood and

prepare it for testing.
nologists use different types of scanners to

produce images of body parts. Examples include
X-ray machines, fluoroscopes, ultrasonic scan-
ners, computerized tomography (CT) scanners
(formerly known as computerized axial tomogra-
phy [CAT] scanners), magnetic resonance imag-
ers (MRI), and positron emission tomography FIGURE 3-18 Radiologic technologists take X-
(PET) scanners. Many radiologic technologists rays used in the diagnosis of disease. (Photo by
also provide radiation treatment. Specific job Marcia Butterfield, courtesy of W. A. Foote Memorial
titles exist for technologists who specialize: Hospital, Jackson, MI)
♦ Radiographers: (figure 3-18) take X-rays of the
body for diagnostic purposes. vascular (blood vessels and blood flow), and
echocardiography (the heart) examinations.
♦ Radiation therapists: administer prescribed
doses of radiation to treat disease (usually ♦ Mammographer: uses a special mammography
cancer). machine to produce images of the breast. The
mammograms are used to assist in the early
♦ Nuclear medicine technologists: prepare radio- detection and treatment of breast cancer.
active substances for administration to
patients. Once administered, these profes- ♦ Computer tomography technologists: use a
sionals use films, images on a screen, or body special X-ray machine called a computerized
specimens such as blood or urine to deter- axial tomography (CT or CAT) scanner to
mine how the radioactive substances pass obtain cross-sectional images of body tissues,
through or localize in different parts of the bones, and organs. CT scans help locate
body. This information is used by physicians tumors and other abnormalities.
to detect abnormalities or diagnose disease. ♦ Magnetic resonance imaging (MRI) technolo-
♦ Ultrasound technologists or diagnostic medi- gists: use superconductive magnets and radio-
cal sonographers: use equipment that sends waves to produce detailed images of internal
high-frequency sound waves into the body. As anatomy. The information is processed by a
the sound waves bounce back from the part computer and displayed on a videoscreen.
being examined, an image of the part is viewed Examples of MRI use include identifying mul-
on a screen. This can be recorded on a print- tiple sclerosis and detecting hemorrhaging
out strip or be photographed. Ultrasound is (bleeding) in the brain.
frequently used to examine the fetus (devel- ♦ Positron emission tomography (PET) technolo-
oping infant) in a pregnant woman and can gists: inject a slightly radioactive substance
reveal the sex of the unborn child. Ultrasound into the patient and then operate the PET
is also used for neurosonography (the brain), scanner, which uses electrons to create a
72 CHAPTER 3
three-dimensional image of body parts and ♦ International Society for Clinical Laboratory
scan the body for disease processes. This Technology
allows physicians to see an organ or bone 917 Locust Street, Suite 1100
from all sides, similar to a model. St. Louis, MO 63101
♦ National Accrediting Agency for Clinical Lab-
oratory Sciences
ADDITIONAL SOURCES 8410 West Bryn Mawr Avenue, Suite 670
Chicago, IL 60631-3415
OF INFORMATION Internet address: www.naacls.org
♦ National Credentialing Agency for Laboratory
♦ Alliance of Cardiovascular Professionals Personnel
4356 Bonney Road, Suite 103 P.O. Box 15945-289
Virginia Beach, VA 23452-1200 Lenexa, KS 66285
Internet address: www.acp-online.org Internet address: www.nca-info.org
♦ American College of Radiology ♦ Society of Diagnostic Medical Sonography
1891 Preston White Drive 2745 Dallas Parkway, Suite 350
Reston, VA 22091 Dallas, TX 75093-8730
Internet address: www.acr.org Internet address: www.sdms.org
♦ American Medical Technologists ♦ For information about specific tasks of a med-
710 Higgins Road ical laboratory assistant/technician and a
Park Ridge, IL 60068 radiology assistant/technician, ask your
Internet address: www.amt1.com instructor for the Guideline for Clinical Rota-
♦ American Registry of Radiologic Technologists tions in the Diversified Health Occupations
1255 Northland Drive Teacher’s Resource Kit. Additional career infor-
St. Paul, MN 55120-1155 mation for medical laboratory assistants/
Internet address: www.arrt.org technicians is provided in the Career High-
♦ American Society for Clinical Laboratory light Section of Chapter 19 in this textbook.
Science
6701 Democracy Boulevard, Suite 300
Bethesda, MD 20814 3:4 INFORMATION
Internet address: www.ascls.org
♦ American Society of Electroneurodiagnostic Health Informatics Careers
Technologists Health informatics workers are involved with
426 W. 42nd Street documentation of patient records and health
Kansas City, MO 64111 information. There are many different types of
Internet address: www.aset.org health workers at all levels. Some examples of
♦ American Society of Radiologic Technologists careers in health informatics include health
15000 Central Avenue SE information administrators or technicians, health
Albuquerque, NM 87123-3917 educators, medical transcriptionists, admitting
Internet address: www.asrt.org office personnel, epidemiologists, medical illus-
trators, photographers, writers, and librarians
♦ Association of Schools of Allied Health (see table 3-15). Computer technology is used in
Professions almost all the careers.
1730 M Street, Suite 500 Places of employment include hospitals, clin-
Washington, DC 20036 ics, research centers, health departments, long-
Internet address: www.asahp.org. term care facilities, colleges, law firms, health
♦ Cardiovascular Credentialing International maintenance organizations (HMOs), and insur-
(CCI) ance companies.
1500 Sunday Drive, Suite 102 Health information (medical records)
Raleigh, NC 27607 administrators (RAs) develop and manage the
Internet address: www.cci-online.org systems for storing and obtaining information
TABLE 3-15 Health Informatics Careers

Health Information • Bachelor’s or master’s degree Above average $41,400–$88,700

(Medical Records) • Registration can be obtained from American Health growth
Administrator Information Management Association (AHIMA)
Registered (RRA)
Health Information • Associate’s degree Above average $22,700–$52,300
(Medical Records) • Registration can be obtained from the American Health growth
Technician Information Management Association (AHIMA) after
Registered (RHIT) passing a written examination
Medical • 1 or more years career or technical education program, Above average $18,700–$37,400
Transcriptionist on-the-job training, or associate’s degree growth
Certified Medical • Certification can be obtained from American Association
Transcriptionist for Medical Transcription
(CMT)
Admitting Officer • 1–2 year HSTE or business/office career/ technical Average growth $15,300–$36,800
or Clerk education
• Admitting manager may require bachelor’s degree
• Few have on-the-job training
Unit Secretary • 1 or more years career or technical education program Average growth $14,200–$34,300
Ward Clerk • Some have on-the-job training
Health Unit
Coordinator
Medical Records
Clerk
Epidemiologist • Master’s or doctoral degree in environmental health, Above average $55,000–$96,500
public health, or health management sciences growth
Medical • Associate’s, bachelor’s, or master’s degree Above average $31,800–$76,300
Interpreter/ • Certification for translators can be obtained from the growth
Translator American Translators Association
• Certification for sign language interpreters can be
obtained from the National Association of the Deaf and
the Registry of Interpreters for the Deaf
Medical Illustrator • Bachelor’s or master’s degree Average growth $43,700–$132,500
• Certification can be obtained from Association of
Medical Illustrators
Medical Librarian • Master’s degree in library science Average growth $41,600–$136,300
from records, prepare information for legal istrator to be able to operate and use a variety of
actions and insurance claims, compile statistics computer programs.
for organizations and government agencies, Health information (medical records)
manage medical records departments, ensure technicians, (figure 3-19), organize and code
the confidentiality of patient information, and patient records, gather statistical or research
supervise and train other personnel. Because data, record information on patient records,
computers are used in almost all aspects of the monitor electronic and paper-based information
job, it is essential for the medical records admin- to ensure confidentiality, and calculate bills using
74 CHAPTER 3
extended care facilities, clinics, and other health

facilities to record information on records; sched-
ule procedures or tests; answer telephones; order
supplies; and work with computers to record or
obtain information.
Epidemiologists identify and track dis-
eases as they occur in a group of people. They
determine risk factors that make a disease more
likely to occur, evaluate situations that may
cause occupational exposure to toxic sub-
stances, develop methods to prevent or control
the spread of new diseases, and evaluate statis-
tics and data to help governments, health agen-
cies, and communities deal with epidemics and
FIGURE 3-19 Health information (medical other health issues. Some may specialize in
records) technicians organize and code patients’ areas such as cancer, cardiovascular (heart and
records. blood vessels) diseases, occupational diseases,
infectious or communicable (spread rapidly
from person to person) diseases, and/or health
health care data. Computers have simplified care research.
many of the duties and are used to organize Medical interpreters/translators assist
records, compile and report statistical data, and cross-cultural communication processes by con-
perform similar tasks. Computer operation is an verting one language to another. Interpreters
important part of the education program for convert the spoken word while translators con-
health information technicians. Medical records vert written material. Medical interpreters/trans-
departments also employ clerks, who organize lators must be proficient at translating words,
records. Clerks typically complete a 1- or 2-year relaying concepts and ideas between languages,
career/technical program, or are trained on the practicing cultural sensitivity, editing written lan-
job. guage, and determining that the communication
Medical transcriptionists use a computer has been comprehended. Sign language inter-
and word processing software to enter data that preters facilitate communication for individuals
has been dictated on recorder by physicians or who are deaf or hard of hearing.
other health care professionals. Examples of data Medical illustrators use their artistic and
include physical examination reports, surgical creative talents to produce illustrations, charts,
reports, consultation findings, progress notes, graphs, and diagrams for health textbooks,
and radiology reports. journals, magazines, and exhibits. Another
Admitting officers/clerks work in the related field is a medical photographer, who takes
admissions department of a health care facility. photographs or records videotapes of surgical
They are responsible for obtaining all necessary procedures, health education information, docu-
information when a patient is admitted to the mentation of conditions before and after recon-
facility, assigning rooms, maintaining records, structive surgery, and legal information such as
and processing information when the patient is injuries received in an accident.
discharged. An admitting manager is a higher Medical librarians, also called health sci-
level of worker in this field, usually having an ences librarians, organize books, journals, and
associate’s or bachelor’s degree. The admitting other print materials to provide health informa-
manager is responsible for supervising staff, tion to other health care professionals. They use
developing and implementing policies and pro- computer technology to create information cen-
cedures for the department, monitoring perfor- ters for large health care facilities or to provide
mance standards, and coordinating the operation information to health care providers. Some librar-
of the department with other departments in the ians specialize in researching information for
health care facility. large pharmaceutical companies, insurance
Unit secretaries, ward clerks, or health agencies, lawyers, industry, and/or government
unit coordinators are employed in hospitals, agencies.
♦ American Translators Association

ADDITIONAL SOURCES 225 Reinekers Lane, Suite 590
OF INFORMATION Alexandria, VA 22314
Internet address: www.atanet.org
♦ American Association for Medical ♦ Association for Professionals in Infection
Transcription Control and Epidemiology
100 Sycamore Avenue 1275 K Street NW, Suite 1000
Modesto, CA 95354–0550 Washington, DC 20005
Internet address: www.aamt.org Internet address: www.apic.org
♦ American Health Information Management ♦ Association of Medical Illustrators
Association P.O. Box 1897
233 N. Michigan Avenue, Suite 2150 Lawrence, KS 66044
Chicago, IL 60601–5800 Internet address: www.ami.org
Internet address: www.ahima.org ♦ Medical Library Association
♦ American Medical Association Commission 65 East Wacker Plaza, Suite 1900
on Accreditation of Allied Health Education Chicago, IL 60602
Programs Internet address: www.mlanet.org
515 N. State Street ♦ Registry of Interpreters for the Deaf
Chicago, IL 60610 333 Commerce Street
Internet address: www.ama-assn.org Alexandria, VA 22314
Internet address: www.rid.org
TABLE 3-16 Support Services Careers

Health Care • Usually master’s or doctoral, but smaller facilities may Above average $48,500–$196,000
Administrator accept a bachelor’s degree growth
Health Services • Licensure required for long-term care facilities
Manager • Certification can be obtained from American College of
Health Care Executives
Biomedical • Bachelor’s or master’s degree Above average $48,500–$108,600
(Clinical) Engineer • Licensure required in some states growth
• Certification available from the International Certification
Commission for Clinical Engineering and Biomedical
Technology
Biomedical • Associate’s or bachelor’s degree Above average $26,300–$58,600
Equipment • Certification can be obtained from the International growth
Technician Certification Commission for Clinical Engineering and
(CBET-Certified) Biomedical Technology of the Association for the
Advancement of Medical Instrumentation
Central/Sterile • On-the-job training or 1–2-year HSTE program Average growth $12,200–$23,500
Supply Technician
Housekeeping • On-the-job training or 1-year career/technical program Above average $12,200–$24,700
Worker Sanitary growth
Manager
76 CHAPTER 3
3:5 INFORMATION
Support Services Careers
Support services workers are involved with creat-
ing a therapeutic environment to provide direct
or indirect patient care. Any hospital or health
care facility requires workers to operate the sup-
port departments such as administration, the
business office, the admissions office, central/
sterile supply, plant operations, equipment main-
tenance, and housekeeping. Each department
has workers at all levels and with varying levels of
education (see table 3-16).
Places of employment include hospitals, clin- FIGURE 3-20 Central/sterile supply workers
ics, long-term care facilities, HMOs, and public prepare all the equipment and supplies used by
health or governmental agencies. other departments in a health care facility.
Health care administrators, also called
health care executives or health services managers electrocardiographs, X-ray units, pacemakers,
plan, direct, coordinate, and supervise delivery of sterilizers, blood-gas analyzers, heart–lung
health care and manage the operation of health machines, respirators, and other similar devices.
care facilities. They are frequently called chief Lives depend on the accuracy and proper opera-
executive officers (CEOs). A health care adminis- tion of many of these machines, so constant
trator may be responsible for personnel, super- maintenance and testing for defects is critical.
vise department heads, determine budget and Some biomedical equipment technicians also
finance, establish policies and procedures, per- teach other staff members how to use biomedical
form public relations duties, and coordinate all equipment.
activities in the facility. Duties depend on the size Central/sterile supply workers (figure
of the facility. 3-20) are involved in ordering, maintaining, and
Biomedical (clinical) engineers combine supplying all the equipment and supplies used
knowledge of engineering with knowledge of by other departments in a health care facility.
biology and biomechanical principles to assist in They sterilize instruments or supplies, maintain
the operation of health care facilities. They design equipment, inventory materials, and fill requisi-
and build sensor systems that can be used for tions from other departments.
diagnostic tests, such as the computers used to Housekeeping workers/sanitary man-
analyze blood; develop computer systems that agers, also called environmental service workers,
can be used to monitor patients; design and pro- help maintain the cleanliness of the health care
duce monitors, imaging machines, surgical facility to provide a pleasant, sanitary environ-
instruments, lasers, and other similar medical ment. They observe all principles of infection
equipment; design clinical laboratories and other control to prevent the spread of disease.
units in a health care facility that uses advanced
technology; and monitor and maintain the oper-
ation of the technologic systems. They frequently ADDITIONAL SOURCES
work with other health team members such as
physicians or nurses to adapt instrumentation or OF INFORMATION
computer technology to meet the specific needs
of the patients and health care team. ♦ American College of Health Care
Biomedical equipment technicians Administrators
(BETs) work with the many different machines 300 N. Lee Street Suite 301
used to diagnose, treat, and monitor patients. Alexandria, VA 22314
They install, test, service, and repair equipment Internet address: www.achca.org
such as patient monitors, kidney hemodialysis ♦ American College of Healthcare Executives
units, diagnostic imaging scanners, incubators, One North Franklin Street, Suite 1700
Internet address: www.ache.org
3:6 INFORMATION
♦ American Health Care Association Biotechnology Research and
1201 L Street NW Development Careers
Washington, DC 20005 Biotechnology career workers are involved with
Internet address: www.ahca.org using living cells and their molecules to make
useful products. They work with cells and cell
♦ American Hospital Association products from humans, animals, plants, and
1 North Franklin Street
microorganisms. Through research and develop-
ment, they help produce new diagnostic tests,
Internet address: www.aha.org
forms of treatment, medications, vaccines to pre-
♦ Association for the Advancement of Medical vent disease, methods to detect and clean up
Instrumentation environmental contamination, and food prod-
3330 Washington Boulevard, Suite 400 ucts. The potential for the use of biotechnology is
Arlington, VA 22201-4598 unlimited.
Internet address: www.aami.org Places of employment include pharmaceuti-
cal companies, chemical companies, agricultural
♦ Biomedical Engineering Society facilities, research laboratories, colleges or uni-
8401 Corporate Drive, Suite 110 versities, government facilities, forensic labora-
Landover, MD 20785 tories, hospitals, and industry. There are many
Internet address: www.bmes.org career opportunities at all levels (table 3-17).
TABLE 3-17 Biotechnology Research and Development Careers

Biological or • Bachelor’s, master’s, or doctoral degree Average growth $52,600–$110,500

Medical • Licensure required in some states
Scientists
Biotechnological • Bachelor’s or master’s degree Average growth $48,600–$82,700
Engineers • Licensure required in some states
(Bioengineers)
Biological • Associate’s or bachelor’s degree Average growth $32,300–$62,500
Technicians • Certification can be obtained from the National
Credentialing Agency for Laboratory Personnel
Process • Associate’s degree Average growth $32,300–$59,400
Technicians • Some have bachelor’s degree
Forensic Science • Associate’s, bachelor’s, or master’s degree Above average $38,600–$67,300
Technicians • Most states do not have licensing or certification growth
requirements
• Must meet proficiency levels established by national
accreditation associations for criminal laboratories
• Certification can be obtained from the American Society
for Clinical Pathology
78 CHAPTER 3
Biological or medical scientists study

living organisms such as viruses, bacteria, proto-
zoa, and other infectious substances. They assist
in the development of vaccines, medicines, and
treatments for diseases; evaluate the relation-
ships between organisms and the environment;
and administer programs for testing food and
drugs. Some work on isolating and identifying
genes associated with specific diseases or inher-
ited traits, and perform research to correct genetic
defects. Some specialties include:
♦ Biochemists: study the chemical composition
of living things
♦ Microbiologists: investigate the growth and
characteristics of microscopic organisms
♦ Physiologists: study the life functions of plants
and animals
♦ Forensic scientists: study cells, fibers, and other
evidence to obtain information about a crime
♦ Biophysicists: study the response and interre-
lationship of living cells and organisms to the
principles of physics, such as electrical or
mechanical energy
Most biological or medical scientists use
research associates and assistants. These associ-
ates or assistants must have high-level math and
science skills, computer technology proficiency,
effective written and oral communication skills,
knowledge of aseptic techniques, and laboratory FIGURE 3-21 Biological technicians perform
skills. many of the laboratory experiments used for
Biotechnological engineers (bioengi- medical research. (Courtesy of CDC Public Health
neers) use engineering knowledge to develop Image Library/James Gathany)
solutions to complex medical problems. They
develop devices such as cardiac pacemakers, Biological technicians must be proficient in the
blood oxygenators, and defibrillators that aid in use of clinical laboratory equipment and com-
the diagnosis and treatment of disease; research puters. They must also be adept at compiling sta-
various metals and other biomaterials to deter- tistics and preparing research reports to
mine which can be used as implants in the human document experiments.
body; design and construct artificial organs, such Process technicians, working under the
as hip replacements, kidneys, heart valves, and supervision of biological scientists or research
artificial hearts; and research the biomechanics physicians, operate and monitor the machinery
of injury and wound healing. that is used to produce biotechnology products.
Biological technicians, working under the They may install new equipment, monitor the
supervision of biological scientists or biotechno- operation process of the equipment, assess qual-
logical engineers, assist in the study of living ity control of the finished product, and enforce
organisms. They perform many of the laboratory environmental and safety regulations. For exam-
experiments used in medical research on dis- ple, a process technician manufacturing drugs
eases such as cancer and acquired immune defi- for a pharmaceutical company may prepare and
ciency syndrome (AIDS). They also assist in the measure raw materials, load the raw materials
development, testing, and manufacturing of into the machinery, set the controls, operate the
pharmaceuticals or medications (figure 3-21). machinery, take test samples for quality control,

A robot that performs heart surgery?
Open-heart surgery is a major surgery. To correct heart defects or blocked blood vessels
in the heart, surgeons must saw the breastbone in two, pull back the ribs, and open the tho-
racic (chest) cavity with an incision that is usually about 1 foot long. In addition, open-heart
surgery requires a team of surgeons and other personnel.
Researchers have developed surgical robots that can perform this surgery with less
trauma to the patient. A physician makes just three small incisions, called ports, into the
chest. A tiny video camera is attached to one arm of a robot and inserted into one port. Sur-
gical instruments, such as a scalpel (knife) or forceps, are attached to other arms on the
robot and inserted into the other two ports as needed. The physician sits in front of a com-
puter screen showing the images from the camera inside the patient. The physician then
uses joystick-like controls to direct the actions of the robotic arms that hold the instruments.
The robot never gets tired as physicians do during long and delicate surgeries. Its hands
never “tremble” and its movements are exact. It simply follows the physician’s instructions
to perform the surgery. The patient recovers quickly and is usually sent home in one or two
days.
Currently, robotic heart surgery is still being researched. Different types of robots are
being evaluated. Researchers are trying to instill more artificial “intelligence” in the robots
being used. However, the future of robotic surgery is promising. Patients with heart defects
or disease may no longer have to dread open-heart surgery. A few small incisions in the
chest will allow a blocked blood vessel to be replaced and a heart condition cured.
and record required information. Process techni-

cians must use aseptic techniques and follow all
ADDITIONAL SOURCES
safety and environmental regulations during the OF INFORMATION
manufacturing process.
Forensic science technicians, also called ♦ American Academy of Forensic Sciences
criminalists, investigate crimes by collecting and P.O. Box 669
analyzing physical evidence. Examples of physi- Colorado Springs, CO 80901
cal evidence include weapons, clothing, shoes, Internet address: www.aafs.org
fibers, hair, body tissues, blood, body fluids, fin- ♦ American Institute of Biological Sciences
gerprints, chemicals, and even vapors in the air. 1444 I. Street NW, Suite 200
After the physical evidence is analyzed and pre- Washington, DC 20005
served, the forensic science technician works Internet address: www.aibs.org
with other investigative officers such as police
detectives to reconstruct a crime scene and find ♦ Biotechnology Industry Organization
the individual who committed the crime. Foren- 1225 Eye Street, NW, Suite 400
sic science technicians must be proficient in the Washington, DC 20005
use of laboratory equipment and computers. Internet address: www.bio.org
They must also be adept at preparing reports, ♦ Biotechnology Institute
compiling statistics, and testifying in trials or 1840 Wilson Boulevard, Suite 202
hearings. Arlington, VA 22201
Internet address: www.biotechinstitute.org
♦ Pharmaceutical Research and Manufacturers
of America
1100 Fifteenth Street, NW
Internet address: www.phrma.org
80 CHAPTER 3
STUDENT: Go to the workbook and complete Programs (CAAHEP) at www.caahep.org and

the assignment sheet for Chapter 3, Careers in the Accrediting Bureau of Health Education
Health Care. Schools (ABHES) at www.abhes.org to deter-
mine which health career programs are accred-
ited by each agency. Research schools in your
area that meet accreditation standards.
CHAPTER 3 SUMMARY 5. Schools: Search for technical schools, colleges,
and universities that offer educational pro-
More than 250 different careers in health care grams for a specific career. Evaluate entrance
provide individuals with opportunities to find requirements, financial aid, and programs of
occupations they enjoy. Each health care career study.
differs somewhat in the type of duties performed,
the education required, the standards that must
be met and maintained, and the salary earned. REVIEW QUESTIONS
This chapter has described some of the major
health care careers. For each career group, levels 1. Explain the differences and similarities
of workers, basic job duties, educational require- between secondary and post-secondary health
ments, anticipated need for workers through the care education?
year 2012, and average yearly salaries were pro- 2. For each of the post-secondary degrees listed,
vided. Use this chapter to evaluate the different state how many years of education are required
health careers, and request additional informa- to obtain the degree. For each degree, give
tion on specific careers from sources listed at three (3) examples of specific health care
the end of the respective career sections. In this careers that require the degree for entry-level
way, you can research various occupational op- workers.
portunities and determine which health care ca- a. Associate’s degree
reer is most appropriate for your interests and b. Bachelor’s degree
abilities. c. Master’s degree
d. Doctorate
INTERNET SEARCHES 3. Differentiate between certification, registra-

tion, and licensure.
Use the suggested search engines in Chapter 12:4 4. What are CEUs? Why are they required in many
of this textbook to search the Internet for addi- health care careers?
5. Name at least four (4) specific careers within
1. National Health Care Skill Standards (NHCSS): each cluster of the National Health Care Skill
review the history and development of health Standards.
care skill standards, and search for additional
information on the health science career 6. What is an entrepreneur? Identify five (5)
cluster. examples of health care careers that may be an
entrepreneur.
2. Health care careers: Search for information on
specific careers by entering the name of the 7. Choose one health care career in which you
career. have an interest. Use references or search the
Internet to list ten (10) specific tasks performed
3. Career organizations: Contact organizations at by personnel in the career.
web addresses listed in each career cluster to
determine the purpose of the organization, 8. Choose one health care career in which you
health careers it promotes, and advantages of have an interest. Use references or search the
membership. Internet to identify three (3) different schools
that offer accredited programs in the career.
4. Accreditation Agencies: Search the Commission
on Accreditation of Allied Health Education
CHAPTER 4 Personal and
Professional
Qualities of a
Health Care Worker
Chapter Objectives
Observe Standard ◆ Explain how diet, rest, exercise, good posture,
Precautions and avoiding tobacco, alcohol, and drugs
contribute to good health
◆ Demonstrate the standards of a professional
Instructor at This Point appearance as they apply to uniforms, shoes,
nails, hair, jewelry, and makeup
◆ Create a characteristic profile of a health care
Safety—Proceed with worker that includes at least eight personal/
Caution
professional traits or attitudes
◆ Identify four factors that interfere with
OBRA Requirement—Based communication
on Federal Law ◆ Explain the importance of listening, nonverbal
behavior, reporting, and recording in the
communication process
Math Skill
◆ Identify why teamwork is beneficial
◆ Identify six basic characteristics of leaders
Legal Responsibility ◆ Differentiate among democratic, laissez-faire,
and autocratic leaders
◆ Differentiate between positive and negative
Science Skill
stressors by identifying the emotional response
◆ List six ways to eliminate or decrease stress
Career Information ◆ Explain how time management, problem
solving, and goal setting reduce stress
Technology
82 CHAPTER 4
KEY TERMS
acceptance of criticism enthusiasm personal hygiene
autocratic leader feedback responsibility
communication goal self-motivation
competence honesty stress
(kom⬘-peh-tense) laissez-faire leader tact
cultural diversity leader team player
democratic leader leadership teamwork
dependability listening time management
discretion nonverbal communication willingness to learn
empathy (em⬘-path-ee⬙) patience
INTRODUCTION als needed for optimum health. Foods from

each of the five major food groups (milk; meat;
Although health care workers are employed in vegetables; fruits; and bread, cereals, rice, and
many different career areas and in a variety of pasta) should be eaten daily. My Pyramid, dis-
facilities, certain personal/professional charac- cussed in Chapter 11:4, identifies the major
teristics, attitudes, and rules of appearance apply food groups.
to all health care professionals. This chapter dis- ♦ Rest: Adequate rest and sleep help provide
cusses these basic requirements. energy and the ability to deal with stress. The
amount of sleep required varies from individ-
4:1 INFORMATION ual to individual.
♦ Exercise: Exercise maintains circulation,
Personal Appearance improves muscle tone, enhances mental atti-
tude, aids in weight control, and contributes
As a worker in any health career, it is important to
to more restful sleep. In addition, regular
present an appearance that inspires confidence
physical activity reduces the risk for coronary
and a positive self-image. Research has shown
heart disease, diabetes, colon cancer, hyper-
that within 20 seconds to 4 minutes people form
tension (high blood pressure), and osteoporo-
an impression about another person based
sis. Individuals should choose the form of
mainly on appearance. Although the rules of suit-
exercise best suited to their own needs, but
able appearance may vary, certain professional
should exercise daily.
standards apply to most health careers and
should be observed to create a positive impres- ♦ Good posture: Good posture helps prevent
sion. fatigue and puts less stress on muscles. Basic
principles include standing straight with
stomach muscles pulled in, shoulders relaxed,
GOOD HEALTH and weight balanced equally on each foot.
♦ Avoid use of tobacco, alcohol, and drugs: The
Health care involves promoting health and pre-
use of tobacco, alcohol, and drugs can seri-
venting disease. Therefore, a health care worker
ously affect good health. Tobacco affects the
should present a healthy appearance. Five main
function of the heart, circulatory system,
factors contribute to good health:
lungs, and digestive system. In addition, the
♦ Diet: Eating well-balanced meals and nutri- odor of smoke is offensive to many individu-
tious foods provides the body with the materials. For these reasons, most health care facili-
Personal and Professional Qualities of a Health Care Worker 83
ties are “smoke-free” environments. The use able. Extreme styles in any type of uniform should
of alcohol and drugs impairs mental function, be avoided. It is important that the health care
decreases ability to make decisions, and worker learn what type and color uniform is
adversely affects many body systems. The use required or permitted and follow the standards
of alcohol or drugs can also result in job loss. established by the place of employment.
Avoiding tobacco, alcohol, and drugs helps
prevent damage to the body systems and con-
tributes to good health. Clothing
If regular clothing is worn in place of a uniform,
the clothing must be clean, neat, and in good
PROFESSIONAL repair (figure 4-2). The style should allow for free-
APPEARANCE dom of body movement and should be appropri-
ate for the job. For example, while clean, neat
When you obtain a position in a health career, it jeans might be appropriate at times for a recre-
is important to learn the rules or standards of ational therapist, they are not proper attire for
dress and personal appearance that have been most other health professionals. Washable fab-
established by your place of employment. Abide rics are usually best because frequent laundering
by the rules and make every effort to maintain a is necessary.
neat, clean, and professional appearance.
Name Badge
Uniform Most health care facilities require personnel to
Many health occupations require uniforms. A wear name badges or photo identification tags at
uniform should always be neat, well fitting, clean, all times. The badge usually states the name, title,
and free from wrinkles (figure 4-1). Some agen- and department of the health care worker. In
cies require a white uniform, but others allow some health care settings, such as long-term care
pastel colors. In some facilities, the colors iden- facilities, workers are required by law to wear
tify groups of workers. If white uniforms are
required, white or neutral undergarments should
be worn. A large variety of uniform styles is avail-
FIGURE 4-1 Uniform styles may vary, but a FIGURE 4-2 If regular clothing is worn in place of
uniform should always be neat, well fitting, clean, a uniform, the clothing should reflect a professional
and free from wrinkles. appearance.
84 CHAPTER 4
identification badges. In addition, a health care Finally, the flash of bright colors may bother a
facility’s security regulations may require photo person who does not feel well. If nail polish is
identification tags to gain access into the build- worn, it should be clear or colorless, and the nails
ing or into certain areas inside the facility. must be kept scrupulously clean. Hand cream or
lotion should be used to keep the hands from
becoming chapped and dry from frequent hand-
Shoes washing.
Although white shoes are frequently required,
many occupations allow other types of shoes.
Any shoes should fit well and provide good sup- Hair
port to prevent fatigue. Low heels are usually best
because they help prevent fatigue and accidents. Hair should be kept clean and neat. It should
Avoid wearing sandals or open-toe shoes, unless be styled attractively and be easy to care for.
they are standard dress for a particular occupa- Fancy or extreme hairstyles, hair ornaments,
tion. Shoes should be cleaned daily. If shoelaces and/or unnatural hair colors should be avoided.
are part of the shoes, these must also be cleaned If the job requires close contact with patients,
or replaced frequently. Women should wear white long hair must be pinned back and kept off
or beige stockings or pantyhose with dress uni- the collar. This prevents the hair from touching
forms; colored or patterned stockings should be the patient/resident, falling on a tray or on
avoided. White socks should be worn with white equipment, or blocking necessary vision during
pants. procedures.
Personal Hygiene Jewelry

Good personal hygiene is essential. Because Jewelry is usually not permitted with a uniform
health care workers typically work in close con- because it can cause injury to the patient and
tact with others, body odor must be controlled. A transmit germs or pathogens. Exceptions some-
daily bath or shower, use of deodorant or antiper- times include a watch, wedding ring, and small,
spirant, good oral hygiene, and clean undergar- pierced earrings. Earrings with hoops or dangling
ments all help prevent body odor. Strong odors earrings should be avoided. Body jewelry, such as
caused by tobacco, perfumes, scented hairsprays, nose, eyebrow, or tongue-piercing jewelry, de-
and aftershave lotions can be offensive. In addi- tracts from a professional appearance and is pro-
tion, certain scents can cause allergic reactions in hibited in many health care facilities. When a
some individuals. The use of these products uniform is not required, jewelry should still be
should be avoided when working with patients limited. Excessive jewelry can interfere with
and co-workers. patient care and detracts from the professional
appearance of the health care worker.
Nails
Nails should be kept short, clean, and natural.
Many health care facilities prohibit the use of
Makeup and Tattoos
artificial nails. If fingernails are long and/or Excessive makeup should be avoided. The pur-
pointed, they can injure patients. They can also pose of makeup is to create a natural appearance
transmit germs, because dirt can collect under and add to the attractiveness of a person.
long nails and artificial nails. In addition, health Tattoos that are visible and/or offensive
care workers are now required to wear gloves for detract from a professional appearance and are
many procedures. Long nails can tear or punc- prohibited in many health care facilities. An
ture gloves. The use of colored nail polish is example is a tattoo on a hand or lower arm that
discouraged because the color can conceal any promotes gang membership. Some health care
dirt that may collect under the nails. Further, facilities require that any tattoo be covered by
because frequent handwashing causes polish to clothing at all times. Learn and follow the policies
chip, germs can collect on the surfaces of nails. established by your place of employment.
♦ Willingness to learn: You must be willing to

4:2 INFORMATION learn and to adapt to changes. The field of
Personal Characteristics health care changes constantly because of
research, new inventions, and technological
Many personal/professional characteristics and advances. Change often requires learning new
attitudes are required in the health occupations. techniques or procedures. At times, additional
As a health care worker, you should make every education may be required to remain compe-
effort to develop the following characteristics and tent in a particular field. Be prepared for life-
attitudes and to incorporate them into your per- long learning to maintain a competent level of
sonality. knowledge and skills.
♦ Empathy: Empathy means being able to ♦ Patience: You must be tolerant and under-
identify with and understand another person’s standing. You must learn to control your tem-
feelings, situation, and motives. As a health per and “count to ten” in difficult situations.
care worker, you may care for persons of all Learning to deal with frustration and over-
ages—from the newborn infant to the elderly come obstacles is important.
adult. To be successful, you must be sincerely
interested in working with people. You must
♦ Acceptance of criticism: Patients, families,
employers, co-workers, and others may criti-
care about others and be able to communi-
cize you. Some criticism will be constructive
cate and work with them. Understanding the
and allow you to improve your work. Remem-
needs of people and learning effective com-
ber that everyone has some areas where per-
munication techniques is one way to develop
formance can be improved. Instead of
empathy. This topic is covered in greater detail
becoming resentful, you must be willing to
in Chapter 4:3 of this text.
accept criticism and learn from it.
♦ Honesty : Truthfulness and integrity are impor-
tant in any career field. Others must be able to
♦ Enthusiasm: You must enjoy your work and
display a positive attitude. Enthusiasm is con-
trust you at all times. You must be willing to
tagious; it helps you do your best and encour-
admit mistakes so they can be corrected.
ages others to do the same. If you do not like
♦ Dependability : Employers and patients rely some aspects of your job, concentrating on
on you, so you must accept the responsibility the positive points can help diminish the
required in your position. You must be prompt importance of the negative points.
in reporting to work, and maintain a good
attendance record (figure 4-3). You must per-
♦ Self-motivation: Self-motivation, or self-
initiative, is the ability to begin or to follow
form assigned tasks on time and accurately.
through with a task. You should be able to
determine things that need to be done and do
them without constant direction. You set goals
for yourself and work to reach the goals.
♦ Tact: Being tactful means having the ability to
say or do the kindest or most fitting thing in a
difficult situation. It requires constant prac-
tice. Tactfulness implies a consideration for
the feelings of others. It is important to remem-
ber that all individuals have a right to their
respective feelings, and that these feelings
should not be judged as right or wrong.
♦ Competence: Being competent means that
you are qualified and capable of performing a
task. You follow instructions, use approved
procedures, and strive for accuracy in all you
FIGURE 4-3 A health care worker must report to do. You know your limits and ask for help or
work on time and maintain a good attendance guidance if you do not know how to perform a
record. procedure.
86 CHAPTER 4
♦ Responsibility : Responsibility implies being

willing to be held accountable for your actions. COMMUNICATION
Others can rely on you and know that you
will meet your obligations. Responsibility
PROCESS
means that you do what you are supposed The communication process involves three
to do. essential elements:
♦ Discretion: You must always use good judg- ♦ Sender: an individual who creates a message
ment in what you say and do. In any health to convey information or an idea to another
care career, you will have access to confiden- person
tial information. This information should not
be told to anyone without proper authoriza- ♦ Message: information, ideas, or thoughts
tion. A patient is entitled to confidential care; ♦ Receiver: an individual who receives the mes-
you must be discreet and ensure that the sage from the sender
patient’s rights are not violated.
Without a sender, message, and receiver, com-
♦ Team player : In any health care field, you munication cannot occur.
will become part of a team. It is essential that Feedback is a method that can be used to
you become a team player and learn to work determine whether communication was success-
well with others. Each member of a health ful. This occurs when the receiver responds to the
care team will have different responsibilities, message. Feedback allows the original sender to
but each member must do his or her part to evaluate how the message was interpreted and to
provide the patient with quality care. By work- make any necessary adjustments or clarification.
ing together, a team can accomplish goals Feedback can be verbal or nonverbal.
much faster than an individual. Even though the communication process
Each of the preceding characteristics and seems simple, many factors can interfere with
attitudes must be practiced and learned. Some the completion of the process. Important ele-
take more time to develop than do others. By ments of effective communication include:
being aware of these characteristics and striving ♦ The message must be clear. The message must
constantly to improve, you will provide good be in terms that both the sender and receiver
patient/resident care and be a valuable asset to understand. Health care workers learn and use
your employer and other members of the health terminology that is frequently not understood
care team. by those people who are not employed in health
care. Even though these terms are familiar to
the health care worker, they must be modified,
4:3 INFORMATION defined, or substituted with other words when
messages are conveyed to people not employed
Effective Communications in health care. For example, if a health care
Communicating effectively with others is an worker needs a urine specimen, some patients
important part of any health career. The can be told to urinate in a container. Others,
health care worker must be able to relate to such as very small children or individuals with
patients and their families, to co-workers, and to limited education, may have to be told to “pee”
other professionals. An understanding of com- or “do number one.” Even a term such as apical
munication skills will assist the health care worker pulse is not understood by many individuals.
who is trying to relate effectively. Instead of telling a patient, “I am going to take
Communication is the exchange of your apical pulse,” say, “I am going to listen to
information, thoughts, ideas, and feelings. It can your heart.” It requires experience and con-
occur through verbal means (spoken words), stant practice to learn to create a message that
written communications, and nonverbal behav- can be clearly understood.
ior such as facial expressions, body language, and ♦ The sender must deliver the message in a clear
touch. and concise manner. Correct pronunciation
and the use of good grammar are essential. The changing the form of the message, and getting
use of slang words or words with double mean- others to interpret or clarify the message are
ings should be avoided. Meaningless phrases some ways to help the receiver receive and
or terms such as “you know,” “all that stuff,” respond to the message.
“um,” and “OK,” distract from the message and
♦ The receiver must be able to understand the
also must be avoided. In verbal communica-
message. Using unfamiliar terminology can
tions, the tone and pitch of voice is important.
cause a breakdown in communication. Many
A moderate level, neither too soft nor too loud,
people do not want to admit that they do not
and good inflection, to avoid monotone, are
understand terms because they think others
essential. Think of the many different ways the
will think they are dumb. The health care
sentence “I really like this job” can be said and
worker should ask questions or repeat infor-
the different meanings that can be interpreted
mation in different terms if it appears that the
depending on the tone and pitch of the voice.
patient does not understand the information.
The proper rate, or speed, of delivering a mes-
The receiver’s attitude and prejudices can also
sage is also important. If a message is delivered
interfere with understanding. If a patient feels
too quickly, the receiver may not have enough
that health care workers do not know what
time to hear all parts of the message. In written
they are talking about, the patient will not
communications, the message should be
accept the information presented. Receivers
spelled correctly, contain correct grammar and
must have some confidence and belief in the
punctuation, and be concise but thorough.
sender before they will accept and understand
♦ The receiver must be able to hear and receive a message. It is important that health care
the message. Patients who are heavily medi- workers are willing to say, “I don’t know, but I
cated or are weak may nod their heads as if will try to find out that information for you,”
messages are heard, when, in reality, the when they are asked a question about which
patients are not receiving the information. they do not have correct knowledge. It is also
They may hear it, but it is not being inter- important for health care workers to be aware
preted and understood because of their physi- of their own prejudices and attitudes when
cal states. Patients with hearing or visual they are receiving messages from patients. If
impairments or patients with limited English- health care workers feel that certain patients
speaking abilities are other examples of indi- are lazy, ignorant, or uncooperative, they will
viduals who may not be able to easily receive not respond correctly to messages sent by
messages (figure 4-4). Repeating the message, these patients. Health care workers must be
aware of these feelings and work to overcome
them so they can accept patients as they are.
♦ Interruptions or distractions must be avoided.
Interruptions or distractions can interfere
with any communication. Trying to talk with
others while answering the phone or writing a
message can decrease the effectiveness of
spoken and/or written communication. Loud
noises or distractions in the form of bright
light or uncomfortable temperature can inter-
rupt communication. When two people are
talking outside in freezing temperatures, for
example, the conversation will be limited
because of the discomfort from the cold. A
small child jumping around or climbing up
FIGURE 4-4 In communicating with a person who and down off a mother’s lap will distract the
has a hearing impairment, face the individual and mother as she is getting instructions from a
speak slowly and distinctly. health care worker. A loud television or radio
88 CHAPTER 4
interferes with verbal messages, because Good listening allowed the patient to express
receivers may pay more attention to the radio fears and opened the way to more effective com-
or television than to the person speaking to munication. In this same case, the entire pattern
them. It is important to eliminate or at least of communication could have been blocked if
limit distractions if meaningful communica- the health care worker had instead responded,
tion is to take place. “That’s good.”
LISTENING NONVERBAL
Listening is another essential part of effective COMMUNICATION
communication. Listening means paying atten-
tion to and making an effort to hear what the Nonverbal communication involves the use
other person is saying. Good listening skills of facial expressions, body language, gestures,
require constant practice. Techniques that can be eye contact, and touch to convey messages or
used to learn good listening skills include: ideas (figure 4-5). If a person is smiling and sit-
ting in a very relaxed position while saying, “I am
♦ Show interest and concern for what the very angry about this entire situation,” two differ-
speaker is saying ent messages are being conveyed. A smile, a
♦ Be alert and maintain eye contact with the frown, a wink, a shrug of the shoulders, a bored
speaker expression, a tapping of fingers or feet, and other
similar body gestures or actions all convey mes-
♦ Avoid interrupting the speaker sages to the receiver. It is important for health
♦ Pay attention to what the speaker is saying care workers to be aware of both their own and
♦ Avoid thinking about how you are going to patients’ nonverbal behaviors because these are
respond an important part of any communication pro-
cess. A touch of the hand, a pat on the back, a
♦ Try to eliminate your own prejudices and see firm handshake, and a hug can convey more
the other person’s point of view
interest and caring than words could ever do.
♦ Eliminate distractions by moving to a quiet When verbal and nonverbal messages agree, the
area for the conversation receiver is more likely to understand the message
♦ Watch the speaker closely to observe actions being sent.
that may contradict what the person is saying
♦ Reflect statements back to the speaker to let
the speaker know that statements are being
heard
♦ Ask for clarification if you do not understand
part of a message
♦ Keep your temper under control and maintain
a positive attitude
Good listening skills will allow you to receive
the entire message a person is trying to convey to
you. For example, if a patient says, “I’m not wor-
ried about this surgery,” but is very restless and
seems nervous, the patient’s body movements
may indicate fear that is being denied by words.
The health care worker could reflect the patient’s
statement by saying, “You’re not at all worried
about this surgery?” The patient may respond by
saying, “Well, not really. It’s just that I worry about FIGURE 4-5 What aspects of listening and
my family if something should happen to me.” nonverbal behavior can you see in this picture?
sary to obtain the assistance of a sign language

BARRIERS TO interpreter to communicate with a deaf indi-
COMMUNICATION vidual.
♦ Blindness or impaired vision: People who are
A communication barrier is something that gets in blind or visually impaired may be able to hear
the way of clear communication. Three common what is being said, but they will not see body
barriers are physical disabilities, psychological language, gestures, or facial expressions. To
attitudes and prejudice, and cultural diversity. improve communication, use a soft tone of
voice, describe events that are occurring,
announce your presence as you enter a room,
Physical Disabilities explain sounds or noises, and use touch when
appropriate.
♦ Deafness or hearing loss: People who are deaf
or hearing impaired have difficulty receiving ♦ Aphasia or speech impairments: Aphasia is the
messages. To improve communication, it is loss or impairment of the power to use or
essential to use body language such as ges- comprehend words, usually as a result of
tures and signs, speak clearly in short sen- injury or damage to the brain. Individuals
tences, face the individual to improve the with aphasia or speech impairments can have
potential for lip reading, write messages if difficulty with not only the spoken word but
necessary, and make sure that any hearing also written communications. They may know
aids have good batteries and are inserted cor- what they want to say but have difficulty
rectly (figure 4-6). At times, it may be neces- remembering the correct words, may not be
able to pronounce certain words, or may have
slurred and distorted speech. Patience is
essential while working with these individu-
als. Allow them to try to speak, encourage
them to take their time, ask questions that
require only short responses, speak slowly and
clearly, pause between sentences to allow
them to comprehend what has been said,
repeat messages to be sure they are correct,
encourage them to use gestures or point to
objects, provide writing materials if they can
write messages, or use pictures with key mes-
sages to communicate (figure 4-7).
Psychological Barriers
Psychological barriers to communication are
often caused by prejudice, attitudes, and per-
sonality. Examples include closed-mindedness,
judging, preaching, moralizing, lecturing, overre-
acting, arguing, advising, and prejudging. Our
judgments of others are too often based on
appearance, lifestyle, and social or economic sta-
tus. Stereotypes such as “dumb blonde,” “lazy
bum,” or “fat slob” cause us to make snap judg-
ments about an individual and affect the com-
munication process.
Health care workers must learn to put prejudice
FIGURE 4-6 To be effective, hearing aids must be aside and show respect to all individuals. A home-
inserted correctly and have good batteries. less person deserves the same quality of health care
90 CHAPTER 4
and customs shared by a group of people and

passed from one generation to the next. It is often
defined as a set of rules, because culture allows
an individual to interpret the environment and
actions of others and behave appropriately. The
main barriers created by cultural diversity
include:
♦ Beliefs and practices regarding health and ill-

ness: Individuals from different cultures may
have their own beliefs about the cause of an
illness and the type of treatment required. It is
important to remember that they have the
right to determine their treatment plans and
even to refuse traditional treatments. At times,
these individuals may accept traditional health
care but add their own cultural remedies to
the treatment plan.
♦ Language differences: Language differences
can create major barriers. In the United States,
English is a primary language used in health
care. If a person has difficulty communicating
in English, and a health care worker is not flu-
FIGURE 4-7 Picture cards make it easier to
ent in another language, a barrier exists. When
communicate with a patient who has aphasia or a
speech impairment.
providing care to people who have limited
English-speaking abilities, speak slowly, use
as the president of the United States. It is important simple words, use gestures or pictures to clar-
to respect each person as an individual and to ify the meaning of words, and use nonverbal
remember that each person has the right to good communication in the form of a smile or gen-
care and considerate treatment. At times, this can tle touch. Avoid the tendency to speak louder
be extremely difficult, and patience and practice because this does not improve comprehen-
are essential. When individuals have negative atti- sion. Whenever possible, try to find an inter-
tudes or constantly complain or criticize your work, preter who speaks the language of the patient.
it can be difficult to show them respect. The health Frequently, another health care worker, a con-
care worker must learn to see beyond the surface sultant, or a family member may be able to
attitude to the human being underneath. assist in the communication process. In addi-
Frequently, fear is the cause of anger or a nega- tion, many health care facilities provide writ-
tive attitude. Allow patients to express their fears or ten instructions or explanations in several
anger, encourage them to talk about their feelings, different languages to facilitate the communi-
avoid arguing, remain calm, talk in a soft and non- cation process (figure 4-8).
threatening tone of voice, and provide quality care. ♦ Eye contact: In some cultures, direct eye-to-
If other health care workers seem to be able to eye contact while communicating is not
communicate more effectively with patients, watch acceptable. These cultures believe that look-
these workers to learn how they handle difficult or ing down shows proper respect for another
angry patients. This is often the most effective individual. A health care worker who feels that
means of learning good communication skills. eye contact is important must learn to accept
and respect this cultural difference and a per-
son’s inability to engage in eye contact while
Cultural Diversity communicating.
Cultural diversity, discussed in detail in Chap- ♦ Ways of dealing with terminal illness and/or
ter 9, is another possible communication barrier. severe disability: In the United States, a tradi-
Culture consists of the values, beliefs, attitudes, tional health care belief is that the patient
al’s right to cultural beliefs, a health care worker

can provide quality health care.
RECORDING AND
REPORTING
In health care, an important part of effective com-
munication is reporting or recording all observa-
tions while providing care. To do this, it is important
to not only listen to what the patient is saying, but
to make observations about the patient. All senses
FIGURE 4-8 Many health care facilities provide are used to make observations:
written instructions or explanations in several ♦ Sense of sight: notes the color of skin, swelling
different languages to facilitate communication with or edema, the presence of a rash or sore, the
individuals who have limited English-speaking color of urine or stool, the amount of food
abilities. eaten, and other similar factors
♦ Sense of smell: alerts a health care worker to
should be told the truth about his or her diag-
body odor or unusual odors of breath, wounds,
nosis and informed about the expected out-
urine, or stool
come. Some cultural groups believe that a
person should not be told of a fatal diagnosis ♦ Sense of touch: used to feel the pulse, dryness
or be burdened with making decisions about or temperature of the skin, perspiration, and
treatment. In these cultures, the family, the swelling
mother or father, or another designated indi- ♦ Sense of hearing: used while listening to respi-
vidual is expected to make decisions about rations, abnormal body sounds, coughs, and
care, treatment, and information given to the speech
patient. In such instances, it is important for
By using all senses, the health care worker
health care workers to recognize and respect
can learn a great deal about a patient’s condition
this and to involve these individuals in the
and be able to report observations accurately.
patient’s care. At times, it may be necessary for
Observations should be reported promptly to
a patient to use legal means, such as power of
an immediate supervisor. There are two types of
attorney for health care, to designate respon-
observations:
sibility for his or her care to another person.
♦ Touch: In some cultures, it is inappropriate to ♦ Subjective observations: These cannot be seen
touch someone on the head. Other cultures or felt, and are commonly called symptoms.
have clearly defined areas of the body that can They are usually statements or complaints
be touched or that should be avoided. Even a made by the patient. They should be reported
simple handshake can be regarded as showing in the exact words the patient used.
a lack of respect. In some cultures, only family ♦ Objective observations: These can be seen or
members provide personal care. For this rea- measured, and are commonly called signs. A
son, health care workers should always get bruise, cut, rash, or swelling can be seen.
permission from the patient before providing Blood pressure and temperature are measur-
care and should avoid any use of touch that able.
seems to be inappropriate for the individual.
For example, the health care worker should
Respect for and acceptance of cultural diver- not state, “I think Mr. B. has a fever.” The report
sity is essential for any health care worker. When should state, “Mr. B. is complaining of feeling hot.
beliefs, ideas, concepts, and ways of life are dif- His skin is red and flushed, and his temperature
ferent, communication barriers can result. By is 102°.”
making every attempt to learn about cultural dif- In some health care facilities, observations are
ferences and by showing respect for an individu- recorded on a patient’s health care record. Effec-
92 CHAPTER 4
tive communication requires these written obser- even prevent other family members from seeing
vations to be accurate, concise, and complete the information. If any health care provider allows
(figure 4-9). The writing should be neat and legi- information to be released from a medical record
ble, and spelling and grammar should be correct. without the patient’s permission, the patient can
Only objective observations should be noted. Sub- file a complaint that the privacy act has been vio-
jective observations that the health care worker lated. This act is discussed in more detail in Chap-
feels or thinks should be avoided. If a patient’s ter 5:1. It is important for every health care
statement is recorded, the statement should be provider to be aware of all parts of this act and to
written in the patient’s own words and enclosed in make every effort to protect the privacy and con-
quotation marks. All information should be signed fidentiality of the patient’s health care records.
with the name and title of the person recording
the information. Errors should be crossed out
neatly with a straight line, have “error” recorded by SUMMARY
them, and show the initials of the person making
the error. In this way, recorded communication Good communication skills allow health care
will be effective communication. workers to develop good interpersonal relation-
The Health Insurance Portability and ships. Patients feel accepted, they feel that others
Accountability Act (HIPAA) has established strict have an interest and concern in them, they feel
standards for maintaining confidentiality of free to express their ideas and fears, they develop
health care records. Under this act, patients have confidence in the health care workers, and they
total control on how information in their medical feel they are receiving quality health care. In addi-
records is used. Patients must be able to see and tion, the health care worker will relate more effec-
obtain copies of their records. They can set limits tively with co-workers and other individuals.
on who can obtain this information. They can
4:4 INFORMATION
Teamwork
In almost any health care career, you will be a
part of an interdisciplinary health care team. The
team concept was created to provide quality
holistic health care to every patient. Teamwork
consists of many professionals, with different
levels of education, ideas, backgrounds, and
interests, working together for the benefit of the
patient. For example, a surgical team might
include the following people:
♦ Admitting clerk: collects admission informa-
tion
♦ Insurance representative: obtains approval for
the surgery
♦ Nurses or patient care technicians: prepare the
patient for surgery
♦ Surgeons: perform the operation
♦ Anesthesiologist: administer anesthetics, med-
ications that decrease pain and/or conscious-
ness
♦ Operating room nurses: assist the surgeon
FIGURE 4-9 Information recorded on health care ♦ Surgical technicians: prepare and pass instru-
records must be accurate, concise, and complete. ments
♦ Housekeepers: clean and sanitize the area

♦ Sterile supply personnel: sterilize the instru-
ments
♦ Recovery room personnel: care for the patient
after surgery
After the surgery is complete, a dietitian,

social worker, physical therapist, occupational
therapist, home health personnel, and other
team members might be needed to assist the
patient as he/she recuperates. Each team mem-
ber has an important job to do. When the team
members work well together, the patient receives
quality care.
Teamwork improves communication and
continuity of care. When a team is assigned to a
particular patient, the patient knows his/her
caregivers and support staff. All the team mem-
bers can help to identify the needs of the patient,
offer opinions on the best type of care, partici- FIGURE 4-10 Most health care teams have
pate as decisions are made on options of care, frequent patient care conferences to establish team
and suggest additional professionals who might goals.
be able to assist with specific needs. This allows a
patient to become more educated about health
care options and to make informed decisions
regarding treatment and care. Leadership is discussed in more detail in Chapter
For a team to function properly, every person 4:5.
on the team must understand the role of each Good interpersonal relationships are also
team member. This knowledge provides a picture essential. Poor interpersonal relationships among
of the patient’s total care plan. It also helps clarify team members can harm the quality of care and
each person’s responsibility and establishes the prevent the team from meeting its goals. In the
goals that the team wants to achieve. Most teams same way, good interpersonal relationships can
have frequent patient care conferences, and in improve the quality of care. Members of a team
many instances, the patient is an active partici- will have different cultural and ethnic back-
pant (figure 4-10). Opinions are shared, options grounds, sexes, ages, socioeconomic statuses,
are discussed, decisions are made, and goals are lifestyle preferences, beliefs, and levels of educa-
established. During the conference, each team tion. Each team member must understand that
member must listen, be honest, express his/her these differences affect the way a person thinks
own opinion, and be willing to try different solu- and acts. Each person must be sensitive to the
tions. hopes, feelings, and needs of other team mem-
A leader is an important part of any team. The bers. The Golden Rule of “treat others as you
leader is responsible for organizing and coordi- would want to be treated” should be the main
nating the team’s activities, encouraging every- rule of teamwork. Some ways to develop good
one to share ideas and give opinions, motivating interpersonal relationships include:
all team members to work toward established ♦ Maintain a positive attitude and learn to laugh
goals, assisting with problems, monitoring the at yourself
progress of the team, and providing reports and ♦ Be friendly and cooperate with others
feedback to all team members on the effective-
ness of the team. A good team leader will also ♦ Assist others when you see that they need
allow others to assume the leadership role when help
circumstances indicate that another person can ♦ Listen carefully when another person is shar-
handle a particular situation more effectively. ing ideas or beliefs
94 CHAPTER 4
♦ Respect the opinions of others even though of others. A myth exists that leaders are born. In
you may not agree with them fact, leaders develop by their own efforts. Leaders
combine visions of excellence with the ability to
♦ Be open-minded and willing to compromise inspire others. They promote positive changes
♦ Avoid criticizing other team members that benefit their professions and the people they
♦ Learn good communication skills so you can serve. Anyone can learn to be a leader by making
share ideas, concepts, and knowledge an effort to understand the principles of leader-
ship. In a group, every member who makes a con-
♦ Support and encourage other team members
tribution to an idea can be considered a leader.
♦ Perform your duties to the best of your ability The leadership in the group passes from person
Conflict among individuals with different to person as each individual contributes to the
personalities is a problem that can occur when a achievement of the group’s goals.
group of people is working as a team. When con- Many different characteristics are assigned to
flict occurs, it is essential for each person to deal a leader. All the characteristics can be learned. In
with the conflict in a positive way. The people this way, leadership becomes a skill or function
involved in the conflict should meet, talk with that can be learned, rather than an inherited set
each other to identify the problem, listen to the of characteristics.
other person’s point of view, avoid accusations Some common characteristics may include:
and hostility, try to determine a way to resolve
♦ Respects the rights, dignity, opinions, and
the problem in a cooperative manner, and put
abilities of others
the agreed-upon solution into action. If a situa-
tion occurs where two people do not feel com- ♦ Understands the principles of democracy
fortable talking privately with each other, a ♦ Works with a group and guides the group
mediator may be able to assist with finding a toward a goal
solution to the problem. Some health care facili-
♦ Believes that changes and improvements can
ties have grievance committees to assist with
be accomplished
conflicts that may occur. If a team is to meet its
goals, conflict must be resolved. ♦ Participates in continuing education and pro-
Legal responsibilities are another important fessional development, and understands the
aspect of teamwork. Each member of a team concept of lifelong learning
must be aware of the legal limitations on duties ♦ Understands own strengths and weaknesses
that can be performed. All members must func- ♦ Displays self-confidence and willingness to
tion within legal boundaries. No team member take a stand
should ever attempt to solve a problem or per-
form a duty that is beyond the range of duties ♦ Communicates effectively and verbalizes ideas
legally permitted. clearly
Effective teams are the result of hard work, ♦ Shows self-initiative, a willingness to work,
patience, commitment, and practice. When each and completes tasks
individual participates fully in the team and ♦ Shows optimism, is open-minded, and can
makes every effort to contribute to the team, the compromise
team achieves success.
♦ Praises others and gives credit to others
♦ Dedicated to meeting high standards
4:5 INFORMATION
Leaders can often be classified into broad
Professional Leadership categories. Some of the categories include:
Leadership is an important concept in health religious, political, club or organizational, busi-
occupations. Leadership is the skill or ability to ness, community, expertise in a particular area,
encourage people to work together and do their and even informal or peer group. Leaders in
best to achieve common goals. A leader is fre- these categories often develop based on their
quently defined as an individual who leads or involvement with the particular category. An
guides others, or who is in charge or in command individual who joins a club or organization may
become a leader when the group elects the indi-

vidual to an office or position of leadership 4:6 INFORMATION
within the group.
Leaders are frequently classified as one of
Stress
three types based on how they perform their Stress can be defined as the body’s reaction to
leadership skills. The three main types of leader any stimulus that requires a person to adjust to a
are democratic, laissez-faire, and autocratic. changing environment. Change always initiates
stress. The stimuli to change, alter behavior, or
♦ Democratic leader: encourages the partici- adapt to a situation are called stressors. Stressors
pation of all individuals in decisions that have can be situations, events, or concepts. Stressors
to be made or problems that have to be solved. can also be external or internal forces. For exam-
This leader listens to the opinions of others, ple, a heart attack is an internal stressor, and a
and then bases decisions on what is best for new job is an external stressor.
the group as a whole. By guiding the individu- No matter what the cause, a stressor will
als to a solution, the leader allows the group to cause the body to go into an alarm or warning
take responsibility for the decision. mode. This mode is frequently called the “fight or
flight” reaction because of the physical changes
♦ Laissez-faire leader: more of an informal that occur in the body. When the warning is
type of leader. This leader believes in nonin-
received from a stressor, the sympathetic nervous
terference in the affairs of others. A laissez-
system prepares the body for action. Adrenaline,
faire leader will strive for only minimal rules
a hormone from the adrenal glands, is released
or regulations, and allow the individuals in a
into the bloodstream. It dilates blood vessels to
group to function in an independent manner
the heart and brain to increase blood circulation
with little or no direction. This leader almost
to these areas. At the same time, it constricts
has a “hands-off” policy, and usually avoids
blood vessels to the skin and other internal
making decisions until forced by circum-
organs, resulting in cool skin, decreased move-
stances to do so. The term laissez-faire comes
ment in the digestive tract, and decreased pro-
from a French idiom meaning “to let alone”
duction of urine. The pupils in the eyes dilate to
and can be translated to mean “allow to act”;
improve vision. Saliva production decreases and
therefore, it is an appropriate term to use for
the mouth becomes dry. The heart beats more
this type of leader.
rapidly, blood pressure rises, and the respiratory
♦ Autocratic leader: often called a “dictator.” rate increases. These actions by the sympathetic
This individual maintains total rule, makes all nervous system help provide the body with a
of the decisions, and has difficulty delegating burst of energy and the stamina needed to
or sharing duties. This type of leader seldom respond to the stressor.
asks for the opinions of others, emphasizes After the individual responds to the stressor
discipline, and expects others to follow direc- and adapts or changes as needed, the parasym-
tions at all times. Individuals usually follow pathetic system slowly causes opposite reactions
this type of leader because of a fear of punish- in the body. This results in fatigue or exhaustion
ment or because of an extreme loyalty. while the body returns to normal and recuper-
ates. If the body is subjected to continual stress
All types of leadership have advantages and with constant “up and down” nervous system
disadvantages. In some rare situations, an auto- reactions, the normal functions of the body will
cratic leader may be beneficial. However, the be disrupted. This can result in a serious illness
democratic leader is the model frequently pre- or disease. Many diseases have stress-related ori-
sented as most effective for group interactions. gins. Examples include migraine headaches, anx-
By allowing a group to share in deciding what, iety reactions, depression, allergies, asthma,
when, and how something is to be done, mem- digestive disorders, hypertension (high blood
bers of the group will usually do what has to be pressure), insomnia (inability to sleep), and heart
done because they want to do it. Respecting the disease.
rights and opinions of others becomes the most Everyone experiences a certain degree of
important guide for the leader. stress on a daily basis. The amount of stress felt
96 CHAPTER 4
usually depends on the individual’s reaction to of stress you are comfortable with, the type of
and perception of the situation causing stress. stress that motivates you effectively, and the type
For example, a blood test can be a routine event of stress that is unpleasant. If a chronic daily
for some individuals, such as a diabetic who per- stressor is heavy traffic on the road to work, it
forms three or four blood tests on a daily basis. may be time to evaluate the possibility of finding
Another individual who is terrified of needles a new way to work, leaving earlier or later to avoid
might feel extreme stress when a blood test is traffic, or finding a way to relax while stuck in
necessary. Many different things can cause stress. traffic. Stressors are problems that must be solved
Examples include relationships with family, or eliminated. One way to do this is to use the
friends, and co-workers; job or school demands; problem-solving method. It consists of the follow-
foods such as caffeine, excessive sweets, and salt; ing steps:
illness; lifestyle; financial problems; family events
such as birth, death, marriage, or divorce; over-
♦ Gather information or data. Assess the situa-
tion to obtain all facts and opinions.
work; boredom and negative feelings; time limi-
tations (too much to do and not enough time to ♦ Identify the problem. Try to identify the real
do it); and failure to achieve goals. stressor and why it is causing a reaction.
Not all stress is harmful. In fact, a small ♦ List possible solutions. Look at all ways to
amount of stress is essential to an individual’s eliminate or adapt to the stressor; include
well-being because it makes a person more alert both good and bad ideas; then, evaluate each
and raises the energy level. The individual is able of the ideas and try to determine how effective
to make quick judgments and decisions, becomes it will be.
more organized, and is motivated to accomplish
♦ Make a plan. After evaluating the solutions,
tasks and achieve goals. The way in which an
choose one that you think will have the best
individual responds to stressors determines
outcome.
whether the situation is helpful or harmful. If
stress causes positive feelings such as excitement, ♦ Act on your solution. Use the solution to your
anticipation, self-confidence, and a sense of problem to see if it has the expected outcome.
achievement, it is helpful. If stress causes nega- Does it allow you to eliminate or adapt to the
tive feelings such as boredom, frustration, irrita- stressor?
bility, anger, depression, distrust of others, ♦ Evaluate the results. Determine whether the
self-criticism, emotional and physical exhaus- action was effective. Did it work or is another
tion, and emotional outbursts, it is harmful. Neg- solution better?
ative stress can also lead to substance abuse. An
♦ Change the solution. If necessary, use a differ-
individual may smoke more, drink large amounts
ent solution that might be more effective.
of alcohol, take drugs, or eat excessively to find
comfort and escape from the negative feelings. Learning to manage a stress reaction is
Prolonged periods of harmful stress can lead to another important way of dealing with stressors.
burnout or a mental breakdown. For this reason, When you become aware that a stressor is caus-
an individual must become aware of the stressors ing a physical reaction in your body, use the fol-
in his/her life and learn methods to control lowing four-step plan to gain control:
them.
The first step in learning how to control stress
♦ Stop: immediately stop what you are doing to
break out of the stress response
is to identify stressors. Recognizing the symp-
toms of “fight or flight” can lead to an awareness ♦ Breathe: take a slow deep breath to relieve the
of the factors that cause these symptoms. By physical tension you are feeling
keeping a list or diary of stressors, an individual ♦ Reflect: think about the problem at hand and
can begin to evaluate ways to deal with the stress- the cause of the stress
ors and/or ways to eliminate them. When stress-
♦ Choose: determine how you want to deal with
ful events occur, note what the event was, why
the stress
you feel stress, how much stress you experience,
and how you deal with the stress. Do you tackle The brief pause that the four-step method
the cause of the stress or the symptom? This type requires allows an individual to become more
of information allows you to understand the level aware of the stressor, the physical reaction to the
stressor, and the actual cause of the stress. This ♦ Think positively: reflect on your accomplish-
awareness can then be used to determine whether ments and be proud of yourself
a problem exists. If a problem does exist, a solu-
tion to the problem must be found.
♦ Develop outside interests: provide time for
yourself; do not allow a job to dominate your
Many other stress-reducing techniques can
life
be used to manage stress. Some of the more com-
mon techniques include: ♦ Seek assistance or delegate tasks: ask others for
help or delegate some tasks to others; remem-
♦ Live a healthy life: eat balanced meals, get suf- ber that no one can do everything all of the
ficient amounts of rest and sleep, and exercise time
on a regular basis
♦ Avoid too many commitments: learn to say
♦ Take a break from stressors: sit in a comfort- “no”
able chair with your feet up
It is important to remember that stress is a
♦ Relax: take a warm bath
constant presence in every individual’s life and
♦ Escape: listen to quiet, soothing music cannot be avoided. However, by being aware of
♦ Relieve tension: shut your eyes, take slow deep the causes of stress, by learning how to respond
breaths, and concentrate on relaxing each when a stress reaction occurs, by solving prob-
muscle that is tense lems effectively to eliminate stress, and by prac-
ticing techniques to reduce the effect of stress, an
♦ Rely on others: talk with a friend and reach out
individual can deal with the daily stressors in his/
to your support system (figure 4-11)
her life and even benefit from them. It is also
♦ Meditate: think about your values or beliefs in important for every health care worker to remem-
a higher power ber that patients also experience stress, especially
♦ Use imagery: close your eyes and use all your when they are dealing with an illness and/or dis-
senses to place yourself in a scene where you ability. The same techniques can be used by the
are at peace and relaxed health care worker to help patients learn to deal
♦ Enjoy yourself: find an enjoyable leisure activ- with stress.
ity or hobby to provide “time outs”
♦ Renew yourself: learn new skills, take part in a 4:7 INFORMATION
professional organization, participate in com-
munity activities, and make every effort to Time Management
continue growing as an individual
One way to help prevent stress is to use time
management. Time management is a system
of practical skills that allows an individual to use
time in the most effective and productive way
possible. Time management helps prevent or
reduce stress by putting the individual in charge,
keeping things in perspective when events are
overwhelming, increasing productivity, using
time more effectively, improving enjoyment of
activities, and providing time for relaxing and
enjoying life.
The first step of time management is to keep
an activity record for a period of several days. This
allows an individual to determine how he/she
actually uses the time available. By listing activi-
ties as they are performed, noting the amount of
time each activity takes, and evaluating how
effective the activity was, an individual can see
FIGURE 4-11 Relaxing and talking with a friend is patterns emerging. Certain periods of the day will
one way to reduce stress. show higher energy levels and an improved qual-
98 CHAPTER 4
ity of work. Other periods may indicate that ♦ Narrow your career choices to the health care
accomplishments are limited because of fatigue. fields that you like best.
Wasted time will also become apparent. Time
spent looking for objects, talking on the tele-
♦ Investigate which high-school courses you
should take to meet college entry require-
phone, playing games on a computer, and doing
ments for these health careers.
things that are not worthwhile is time that can be
put to more constructive use. After this informa- ♦ Take the required courses in English, math,
tion has been obtained, an individual can begin science, computer technology, and other spe-
to organize time. Important projects can be cific academic areas.
scheduled during the periods of the day when ♦ Explore the career and technology programs
energy levels are high. Rest or relaxation periods offered by your high school.
can be scheduled when energy levels are low.
♦ Enroll in a health science technology educa-
tion (HSTE) program if one is available.
SETTING GOALS ♦ Join a student organization for HSTE students
to network with other people who have simi-
Goal setting is another important factor of time lar interests.
management. A goal can be defined as a desired
♦ Obtain a job or work as a volunteer in health
result or purpose toward which one is working.
care areas to determine which career you like
Goals can be compared with maps that help you
best.
find your direction and reach your destination.
An old saying states, “If you don’t know where you ♦ Research and visit different colleges or techni-
are going, you will never get there.” Goals allow cal schools to learn about course offerings,
you to know where you are going and provide financial aid, entry requirements, and other
direction to your life. similar information.
Everyone should have both short- and long- When this person is in the junior or senior
term goals. Long-term goals are achievements year of high school, short-term goals might
that may take a period of years or even a lifetime include:
to accomplish. Short-term goals usually take
days, weeks, or months to accomplish. They are ♦ Complete all required high-school courses
the smaller steps that are taken to reach the long- and maintain a high grade point average.
term goal. For example, a long-term goal might ♦ Confer with guidance or career counselors to
be to graduate from college with a health care obtain information on scholarships, financial
degree. help, career planning, college life, and other
If the person with this goal is starting high similar topics.
school, short-term goals might include:
♦ Apply to several colleges or technical schools
♦ Research and learn about the wide variety of that have accredited programs in the chosen
health careers. health field.
♦ Job-shadow health careers that seem most ♦ Arrange for financial assistance and/or obtain
interesting. a part-time job to save money for college.
♦ Talk with people in different health care ♦ Check living arrangements at the college areas
careers to find out about the careers. if living away from home will be necessary.
♦ Complete job interest surveys to determine ♦ After being accepted by colleges or technical
how your own skills and interests match schools, evaluate each individually to choose
requirements for different health careers. the school you will attend.
♦ Discuss career opportunities with a guidance ♦ Notify the school you have selected before the
or career counselor. established deadline for enrollment.
♦ Attend job fairs or career planning days to These short-term goals are basic suggestions.
obtain information on specific health careers. Each individual has to establish his/her own
♦ Use a computer to research health careers on goals. It is important to remember that short-
the Internet. term goals will change constantly as one set is
completed and a new set is established. Comple- from the most important to the least impor-
tion of a goal, however, will lead to a sense of sat- tant; decide if any tasks can be delegated to
isfaction and accomplishment, and provide another person to complete and delegate
motivation to attempt other goals. To set goals whenever possible; eliminate unnecessary
effectively, you must observe certain points. tasks
These points include: ♦ Identify habits and preferences: know when
♦ State goals in a positive manner. Use words you have the most energy to complete work
such as “accomplish” rather than “avoid.” and when it is best to schedule rest, exercise,
♦ Define goals clearly and precisely. If possible, or social activities
set a time limit to accomplish the goal. ♦ Schedule tasks: use the daily planner and cal-
♦ Prioritize multiple goals. Determine which endar to write down all events; be sure to
goals are the most important and complete include time for rest, exercise, meals, hobbies,
them first. and social activities; if a conflict arises with
two things scheduled at the same time, priori-
♦ Write goals down. This makes the goal seem tize and reschedule
real and attainable.
♦ Make a daily “to do” list: list all tasks on a daily
♦ Make sure each goal is at the right level. Goals basis; as you complete each one, cross it off
should present a challenge, but not be too dif-
the list; enjoy the sense of satisfaction that
ficult or impossible to complete.
occurs as you complete each job; if some
After goals have been established, concen- things on the list are not completed at the end
trate on ways to accomplish them. Review neces- of the day, determine if they should be added
sary skills, information that must be obtained, to the next day’s list or if they can be elimi-
resources you can use, problems that may occur, nated
and which goal should be completed first. Basi-
♦ Plan your work: work at a comfortable pace;
cally, this is just organizing the steps that will lead
try to do the hardest tasks first; do one thing at
to achieving the goal. After the goal has been
a time whenever possible so you can complete
achieved, enjoy your sense of accomplishment
it and cross it off the list; make sure you have
and satisfaction for a job well done. If you fail in
everything you need to complete the task
obtaining the goal, evaluate the situation and
before you begin; ask for assistance when
determine why you failed. Was the goal unrealis-
needed; work smarter, not harder
tic? Did you lack the skills or knowledge to obtain
the goal? Is there another way to achieve the goal? ♦ Avoid distractions: make every effort to avoid
Remember that failure can be a positive learning interruptions; use a telephone answering sys-
experience. tem and screen calls; avoid procrastination;
learn to say “no” when asked to interrupt your
work for something that is not essential
TIME MANAGEMENT ♦ Take credit for a job well done: when a job is
PLAN complete, recognize your achievement; cross
the completed work off the list; if the task was
Time management is used to ensure success in a particularly hard one, reward yourself with a
meeting established goals. A daily planner and short break or other positive thing before
calendar are essential tools. These tools allow an going on to the next job on the list
individual to write everything down, organize all
These steps of time management provide for an
information, become aware of conflicts (two
organized and efficient use of time. However,
things to do at the same time), and provide an
even with careful planning, things do not always
organized schedule to follow. An effective time
get done according to plan. Unexpected emer-
management plan involves the following seven
gencies, a new assignment, a complication, and/
steps:
or overscheduling are common events in the life
♦ Analyze and prioritize: review and list estab- of a health care worker. When a time manage-
lished goals; determine what tasks must be ment plan does not work, try to determine the
completed to achieve goals; list tasks in order, reasons for failure. Reevaluate goals and revise
100 CHAPTER 4
the plan. Patience, practice, and an honest effort ity time for rest and relaxation, a sense of being in
will eventually produce a plan that provides self- control, a healthier lifestyle, and increased pro-
satisfaction for achieving goals, less stress, qual- ductivity.

Melting fat to lose weight?
According to statistics from the National Health and Nutrition Examination Survey,
nearly two-thirds of adults in the United States are overweight. In addition, more than one-
third of these individuals are extremely overweight, or obese (20 percent or more above the
recommended weight). Research has shown that obesity is a risk factor for the development
of diabetes, heart disease, hypertension (high blood pressure), stroke, and even some forms
of cancer.
Scientists are now researching a unique approach to treat obesity. They are trying to
starve adipose (fatty) tissue by destroying the blood vessels that feed it. Fat cells grow
and multiply quickly by creating tiny blood vessels called capillaries, which provide nour-
ishment. Estimates are that 1 pound of fat contains a mile of blood vessels. A protein, pro-
hibitin, located on the surface of fat-feeding blood vessels, seems to regulate cell growth.
Scientists have developed a compound that attaches to prohibitin and selectively destroys
the blood vessels. When the compound was injected into obese mice, the mice lost about 30
percent of their body weight within 4 weeks. Further research is now being conducted to
determine the effect of this compound on baboons.
One obstacle to using this compound in humans is that prohibitin is found in cells
throughout the body. Care will have to be taken to make sure that other tissues and blood
vessels are not destroyed. If researchers are able to create a substance that destroys only the
blood vessels to adipose tissue, they will be able to “melt” fat by literally starving it to death.
If this occurs, obesity and many of the diseases caused by obesity will be eliminated.
STUDENT: Go to the workbook and complete avoiding the use of tobacco, alcohol, and drugs,
the assignment sheet for Chapter 4, Personal and a health care worker can strive to maintain good
Professional Qualities of a Health Care Worker. health. Wearing the appropriate uniform or ap-
propriate clothing and shoes is essential to pro-
CHAPTER 4 SUMMARY jecting the proper image. Proper hair and nail
care, good personal hygiene, and limited make-
up also help create a professional appearance.
Certain personal characteristics, attitudes, and Personal characteristics such as honesty, de-
rules of appearance apply to health care workers pendability, patience, enthusiasm, responsibil-
in all health careers. Every health care worker ity, discretion, and competence are essential. In
must constantly strive to develop the necessary addition, health care workers must be willing to
characteristics and to present a professional ap- learn and to accept criticism. These characteris-
pearance. tics must be practiced and learned.
A professional appearance helps inspire con- Effective communication is an important
fidence and a positive self-image. Good health aspect of helping individuals through stages of
is an important part of appearance. By eating growth and development and in meeting needs.
correctly, obtaining adequate rest, exercising A health care worker must have an understand-
daily, observing the rules of good posture, and ing of the communication process, factors that
interfere with communication, the importance preparing written “to do” lists and crossing off
of listening, and verbal and nonverbal commu- work that has been completed, planning work
nication. Another important aspect of commu- carefully, avoiding distractions, and taking cred-
nication is the proper reporting or recording of it for a job well done. An effective time manage-
all observations noted while providing care. ment plan will reduce stress, help an individual
Communication barriers such as physical attain goals, increase self-confidence, lead to a
disabilities, psychological attitudes, and cultural healthier lifestyle, and provide quality time for
diversity can interfere with the communication rest and relaxation.
process. Special consideration must be given to Health care workers must learn and follow
these barriers to improve communication. Some the standards and requirements established by
cultural groups have beliefs and practices that the health care facility in which they are em-
may relate to health and illness. Because indi- ployed.
viduals will respond to health care according to
their cultural beliefs, a health care worker must
be aware of and show respect for different cul- INTERNET SEARCHES
tural values in order to provide optimal patient
care. Use the suggested search engine in Chapter 12:4
Teamwork is important in any health care of this textbook to search the Internet for addi-
career. Interdisciplinary health care teams pro- tional information on the following topics:
vide quality holistic health care to every patient.
1. Uniform companies: search “uniform suppli-
Teamwork improves communication and conti-
ers” to locate companies that sell professional
nuity of care. A picture of the patient’s total care
uniforms and compare styles, prices, and so
plan is clear when the role of each team member
forth.
is known. For a team to function effectively, it
needs a qualified leader, good interpersonal re- 2. Professional characteristics: choose a specific
lationships, ways to avoid or deal with conflict, health care career and search for career
positive attitudes, and respect for legal respon- descriptions; list the required personal quali-
sibilities. Effective teams are the result of hard ties or characteristics necessary for the career
work, patience, commitment, and practice. you have chosen.
Leadership is a skill that can be learned 3. Communication: search for information on
by mastering the characteristics of a leader. A listening skills, nonverbal communication, and
leader may or may not be a supervisor; any mem- the communication process.
ber of a group that contributes to the group’s
goals can be considered a leader. Of the three 4. Leadership: search for information on types
types of leaders—democratic, laissez-faire, and and characteristics of leaders; evaluate which
autocratic—the democratic leader is the most types would be most effective in guiding a
effective for group interaction. health care team.
Stress is a component in every individual’s 5. Stress: search for information on stress and
life. Stress can be good or bad, depending on the stress-reducing techniques.
person’s perception of and reaction to the stress.
By being aware of the causes of stress, learning 6. Time management: search for information on
how to respond when a stress reaction occurs, time management.
solving problems to eliminate stress, and prac-
ticing techniques to reduce the effect of stress,
an individual can deal with stress and even ben- REVIEW QUESTIONS
efit from it.
Time management is a system of practi- 1. What five (5) main factors contribute to good
cal skills that allow an individual to use time in health?
the most effective and productive way possible.
2. Identify eight (8) specific principles that must
It involves analyzing how one actually uses the
be followed for a professional appearance.
time available, establishing short- and long-
term goals, prioritizing tasks that must be ac- 3. Create a personal description of yourself
complished, identifying habits and preferences, showing why you display at least six (6) of the
102 CHAPTER 4
personal characteristics desired in a health 8. List six (6) characteristics of an effective leader.
care worker.
9. Identify the three (3) types of leaders and
4. Why is it important to observe both verbal and describe their style of leadership.
nonverbal communication? Create a specific
10. Identify at least one major stress in your life.
example of a situation showing how both
List the steps of the problem-solving method
verbal and nonverbal communication convey a
and then apply the stressor you have chosen to
message.
each of the steps. Identify at least three (3)
5. List five (5) factors that can interfere with the courses of action that you can take.
communication process. Give two (2) specific
11. List six (6) stress-reducing techniques that you
examples for each factor.
find beneficial. State why they help you reduce
6. Differentiate between objective and subjective stress.
observations. List two (2) examples for each
12. Differentiate between short- and long-term
type of observation.
goals. How are they related? How are they
7. A patient is admitted to a hospital to give birth different?
to her baby. Identify at least ten (10) health care
13. What are the main goals of time management?
professionals who may be on the team that
provide her care. Review the many careers in
Chapter 3 to prepare your list.
CHAPTER 5 Legal and Ethical
Responsibilities
Chapter Objectives
Observe Standard
Precautions
◆ Provide one example of a situation that might
result in legal action for each of the following:
malpractice; negligence; assault and battery;
Instructor’s Check—Call invasion of privacy; false imprisonment;
Instructor at This Point abuse; and defamation
◆ Describe how contract laws affect health care
Caution
◆ Define privileged communications and explain
how they apply to health care
◆ State the legal regulations that apply to health
on Federal Law
care records
◆ Define HIPAA and explain how it provides
confidentiality for health care information
Math Skill
◆ List at least six basic rules of ethics for health
care personnel
◆ List at least six rights of the patient who is
receiving health care
Science Skill
◆ Justify at least eight professional standards by
explaining how they help meet legal/ethical
Career Information requirements
Technology
104 CHAPTER 5
KEY TERMS
abuse Durable Power of Attorney living wills
advance directives (POA) malpractice
agent ethics (eth⬘-iks) negligence (neg⬘-lih-gents)
assault and battery expressed contracts Patient Self-Determination
civil law false imprisonment Act (PSDA)
confidentiality (con⬙-fih-den- health care records Patient’s Bill of Rights
chee⬙-ahl⬘-ih-tee) implied contracts patients’ rights
contract informed consent privileged communications
criminal law invasion of privacy Resident’s Bill of Rights
defamation legal slander
(deff⬙-ah-may⬘-shun) legal disability tort
Designation of Health Care libel (ly⬘-bull)
Surrogate
5:1 INFORMATION property, or society; examples include practic-

ing in a health profession without having the
Legal Responsibilities required license, illegal possession of drugs,
misuse of narcotics, theft, sexual assault, and
murder
INTRODUCTION ♦ Civil law : focuses on the legal relationships
between people and the protection of a per-
In every aspect of life, there are certain laws and son’s rights; in health care, civil law usually
legal responsibilities formulated to protect you involves torts and contracts
and society. An excellent example is the need to
obey traffic laws when driving a motor vehicle. A
worker in any health career also has certain
responsibilities. Being aware of and following
TORTS
legal regulations is important for your own pro- A tort is a wrongful act that does not involve a
tection, the protection of your employer, and the contract. It is called a civil wrong instead of a
safety and well-being of the patient. crime. A tort occurs when a person is harmed or
Legal responsibilities are those that are injured because a health care provider does not
authorized or based on law. A law is a rule that meet the established or expected standards of
must be followed. Laws are created and enforced care. Many different types of torts can lead to
by the federal, state, or local government. Health legal action. These offenses may be quite com-
care workers must follow any laws that affect plex and may be open to different legal interpre-
health care. In addition, health care professionals/ tations. Some of the more common torts include
workers are also required to know and follow the the following:
state laws that regulate their respective licenses or
♦ Malpractice: Malpractice can be interpreted
registrations or set standards for their respective
as “bad practice” and is commonly called
professions. Failure to meet your legal responsi-
“professional negligence.” It can be defined as
bilities can result in legal action against you and
the failure of a professional to use the degree
your employer.
of skill and learning commonly expected in
Two main types of laws affect health care
that individual’s profession, resulting in injury,
workers: criminal laws and civil laws.
loss, or damage to the person receiving care.
♦ Criminal law : focuses on behavior known as Examples might include a physician not
crime; deals with the wrongs against a person, administering a tetanus injection when a
Legal and Ethical Responsibilities 105
patient has a puncture wound, or a nurse per- sent is permission granted voluntarily by a
forming minor surgery without having any person who is of sound mind after the proce-
training. dure and all risks involved have been explained
♦ Negligence: Negligence can be described as in terms the person can understand. It is
failure to give care that is normally expected of important to remember that a person has the
a person in a particular position, resulting in right to withdraw consent at any time. There-
injury to another person. Examples include fore, all procedures must be explained to the
falls and injuries that occur when siderails are patient, and no procedure should be per-
left down (figure 5-1), using or not reporting formed if the patient does not give consent.
defective equipment, infections caused by the ♦ Invasion of privacy : Invasion of privacy
use of nonsterile instruments and/or supplies, includes unnecessarily exposing an individual
and burns caused by improper heat or radia- or revealing personal information about an
tion treatments. individual without that person’s consent.
♦ Assault and battery : Assault includes a Examples include improperly draping or cov-
threat or attempt to injure, and battery ering a patient during a procedure so that
includes the unlawful touching of another other patients or personnel can see the patient
person without consent. They are closely exposed; sending information regarding a
related and often used together. Examples of patient to an insurance company without the
assault and battery include performing a pro- patient’s written permission; or informing the
cedure after a patient has refused to give per- news media of a patient’s condition without
mission, threatening a patient, and improper the patient’s permission.
handling or rough treatment of a patient while ♦ False imprisonment: False imprisonment
providing care. refers to restraining an individual or restrict-
It is important to remember that patients ing an individual’s freedom. Examples include
must give consent for any care, and that they keeping patients hospitalized against their
have the right to refuse care. Some procedures will, or applying physical restraints without
or practices require written consent from the proper authorization or with no justification.
patient. Examples can include surgery, certain It is important to remember that patients
diagnostic tests, experimental procedures, have the right to leave a hospital or health care
treatment of minors (individuals younger than facility without a physician’s permission. If
legal age, which varies from state to state), and this occurs, the patient is usually asked to sign
even simple things such as siderail releases for an AMA (Against Medical Advice) form. If the
a patient who wants siderails left down when patient refuses to sign the form, this must be
other factors indicate siderails should be up to documented in the patient record and the
protect the patient. Verbal consent is permit- physician must be notified.
ted in other cases, but the law states that this Physical restraints, devices used to limit a
must be “informed consent.” Informed con- patient’s movements, are discussed in detail
in Chapter 21:12. They should be used only to
protect patients from harming themselves or
others and when all other measures to control
the situation have failed. A physician’s order
must be obtained before they are used, and
strict guidelines must be observed while they
are in use.
♦ Abuse: Abuse includes any care that results in
physical harm, pain, or mental anguish. Exam-
ples of types of abuse include:
♦ Physical abuse: hitting, forcing people against
FIGURE 5-1 A nurse assistant could be charged their will, restraining movement, depriving
with negligence if a patient is injured by falling out of people of food or water, and/or not providing
bed because siderails are not raised. physical care
106 CHAPTER 5
♦ Verbal abuse: speaking harshly, swearing or ernment agency when laboratory results are inac-
shouting, using inappropriate words to curate, telling others that a person has a drug
describe a person’s race or nationality, and/or problem when another medical condition actually
writing threats or abusive statements exists, or saying that a co-worker is incompetent.
♦ Psychological abuse: threatening harm; deny-
ing rights; belittling, intimidating, or ridicul-
ing the person; and/or threatening to reveal
information about the person
CONTRACTS
♦ Sexual abuse: any unwanted sexual touching In addition to tort laws, contract laws also affect
or act, using sexual gestures, and/or suggest- health care. A contract is an agreement between
ing sexual behavior two or more parties. Most contracts have three
parts:
Patients may experience abuse before enter-
♦ Offer: a competent individual enters into a
ing a health care facility. Domestic abuse occurs
relationship with a health care provider and
when an intimate partner uses threatening,
offers to be a patient
manipulative, aggressive, or violent behavior to
maintain power and control over another person. ♦ Acceptance: the health care provider gives an
If abuse is directed toward a child, it is child appointment or examines or treats the
abuse. If it is directed toward an older person, it is patient
elder abuse. Health care providers must be alert ♦ Consideration: the payment made by the
to the signs and symptoms that may indicate patient for the services provided
patients in their care are victims of abuse. These
Contracts in health care are implied or
may include:
expressed. Implied contracts are those obliga-
♦ unexplained bruises, fractures, burns, or inju- tions that are understood without verbally
ries expressed terms. For example, when a qualified
health worker prepares a medication and a
♦ signs of neglect such as poor personal
patient takes the medication, it is implied that
hygiene
the patient accepts this treatment. Expressed
♦ irrational fears or a change in personality contracts are stated in distinct and clear lan-
♦ aggressive or withdrawn behavior guage, either orally or in writing. An example is a
♦ patient statements that indicate abuse or surgery permit. Promises of care must be kept.
neglect Therefore, all risks associated with treatment
must be explained completely to the patient (fig-
Many of the other torts can lead to charges of ure 5-2).
abuse, or a charge of abuse can occur alone. Laws All parties entering into a contract must be
in all states require that any form of abuse be free of legal disability. A person who has a legal
reported to the proper authorities. Even though disability does not have the legal capacity to form
the signs and symptoms do not always mean a a contract. Examples of people with legal disabil-
person is being abused, their presence indicates ities are minors (individuals under legal age),
a need for further investigation. Health care work- mentally incompetent persons, individuals under
ers are required to report any signs or symptoms the influence of drugs that alter the mental state,
of abuse to their immediate supervisor or to the and semiconscious or unconscious people. In
individual in the health care facility responsible such cases, parents, guardians, or others permit-
for reporting the suspicions to the proper author- ted by law must form the contract for the indi-
ities. vidual.
Defamation: Defamation occurs when false A contract requires that certain standards of
statements either cause a person to be ridiculed or care be provided by competent, qualified indi-
damage the person’s reputation. Incorrect infor- viduals. If the contract is not performed accord-
mation given out in error can result in defamation. ing to agreement, the contract is breached. Failure
If the information is spoken, it is slander; if it is to provide care and/or giving improper care on
written, it is libel. Examples include reporting the part of the health provider, or failure on the
that a patient has an infectious disease to a gov- part of the patient to pay according to the consid-
PRIVILEGED
COMMUNICATIONS
Privileged communications are another
important aspect of legal responsibility. Priv-
ileged communications comprise all information
given to health care personnel by a patient; by law,
this information must be kept confidential and
shared only with other members of the patient’s
health care team. It cannot be told to anyone else
without the written consent of the patient. The
consent should state what information is to be
released, to whom the information should be
given, and any applicable time limits. Certain
information is exempt by law and must be reported.
Examples of exempt information are births and
deaths; injuries caused by violence (such as assault
and battery, abuse, stabbings) that may require
police involvement; drug abuse; communicable
FIGURE 5-2 All risks of treatment must be
diseases; and sexually transmitted diseases.
explained to a patient before asking the patient for
permission to administer treatment.
Health care records are also considered
privileged communications. Such records
contain information about the care provided to
the patient. Although such records belong to the
eration, can be considered breach of contract and health care provider (for example, the physician,
cause for legal action. dentist, hospital, long-term care facility), the
To comply with legal mandates, an inter- patient has a right to obtain a copy of any infor-
preter/translator must be used when a con- mation in the record. Health care records can be
tract is explained to a non-English-speaking used as legal records in a court of law. Erasures
individual. In addition, many states require the are therefore not allowed on such records. Errors
use of interpreter services for individuals who are should be crossed out with a single line so mate-
deaf or hard of hearing. Most health care agen- rial is still readable. Correct information should
cies have a list of interpreters who can be used in then be inserted, initialed, and dated. If neces-
these situations. At times, an English-speaking sary, an explanation for the correction should
relative or friend of the patient can also serve as also be provided. Health care records must be
an interpreter. properly maintained, kept confidential, and
A final important consideration in contract retained for the amount of time required by state
law is the role of the agent. When a person works law (figure 5-3). When records are destroyed after
under the direction or control of another person, the legal time for retention, they should be burned
the employer is called the principal, and the or shredded to maintain confidentiality.
person working under the employer is called The growing use of computerized records has
the agent. The principal is responsible for the created a dilemma in maintaining confidentiality
actions of the agent and can be required to pay or (figure 5-4). In a large health care facility such as a
otherwise compensate people who have been hospital, many different individuals may have
injured by the agent. For example, if a dental access to a patient’s records. For this reason, health
assistant tells a patient “your dentures will look care providers are creating safeguards to maintain
better than your real teeth,” the dentist may have computer confidentiality. Some examples include
to compensate the patient financially should this limiting personnel who have access to such
statement prove false. Health care workers should records, using codes to prevent access to certain
therefore be aware of their role as agents of their information, requiring passwords to access spe-
employers and work to protect the interests of cific information on records, and constantly mon-
their employers. itoring and evaluating computer use.
108 CHAPTER 5
ability Act (HIPAA) of 1996, Congress required the

U.S. Department of Health and Human Services
(USDHHS) to establish standards to protect
health information. The USDHHS published the
Standards for Privacy of Individually Identifiable
Health Information (commonly called the Pri-
vacy Rule), which went into effect in 2003. These
standards provide federal protection for privacy
of health information in all states.
HIPAA regulations in the Privacy Rule require
every health care provider to inform patients
about how their health information is used.
Patients must sign a consent form (figure 5-5)
ascertaining that they have received the infor-
mation before any health care provider can
use the health information for diagnosis, treat-
ment, billing, insurance claims, or quality care
assessments.
FIGURE 5-3 Confidentiality must be maintained In addition, before a health care provider can
with regard to health care records. release information to anyone else, such as
another health care provider, attorney, insurance
company, federal or state agency, or even other
members of the patient’s family, a patient must
sign an authorization form for the release of this
information (figure 5-6). This authorization form
must identify the purpose or need for the infor-
mation, the extent of the information that may be
released, any limits on the release of information,
the date of authorization, and the signature of
the person authorized to give consent. These
requirements are used to ensure the privacy and
confidentiality of a patient’s health care informa-
tion. The only exception to these regulations is
for the release of information on diseases or inju-
ries that must be reported by law to protect the
safety and welfare of the public. Examples of
exempt information include births, deaths, inju-
ries caused by violence that require police
involvement, communicable diseases, and sexu-
ally transmitted diseases.
Other requirements of the privacy standards
are that patients must be:
FIGURE 5-4 The growing use of computerized
records has created the need for limiting access to ♦ able to see and obtain copies of their medical
computers to maintain confidentiality. records
♦ given information by health care providers
about how they use medical information
PRIVACY ACT ♦ allowed to set limits on how personal health
The federal government is concerned about pro- information is used
tecting privileged communications and main- ♦ permitted to request that health care provid-
taining confidentiality of health care records. In ers take reasonable care to keep communica-
the Health Insurance Portability and Account- tions confidential
FIGURE 5-5 Example of a Health Insurance Portability and Accountability Act (HIPAA) required form
providing consent to the use and disclosure of health information.
110 CHAPTER 5
FIGURE 5-6 Example of an authorization to release health information form.
♦ given the right to state who has access to their Health care providers must be aware of these
information, and even limit providing infor- standards and make every effort to protect the
mation to their family privacy and confidentiality of a patient’s health
care information.
♦ provided with information on how to file a
complaint against a health care provider who
violates the privacy act
♦ If a person can benefit from marijuana, should

SUMMARY a physician be allowed to prescribe it as a
Legal responsibilities are important aspects of treatment?
health care. All states have rules and regulations ♦ Should animals be used in medical research
governing health care. In addition, most health even if it results in the death of the animal?
care agencies have specific rules, regulations, and ♦ Should genetic researchers be allowed to
standards that determine activities performed by transplant specific genes to create the “per-
individuals holding different positions of employ- fect” human being?
ment. Standards can vary from state to state, and
even from agency to agency. It is important to
♦ Should human beings be cloned?
remember that you are liable, or legally respon- ♦ Should aborted embryos be used to obtain
sible, for your own actions regardless of what stem cells for research, especially since scien-
anyone tells you or what position you hold. tists may be able to use the stem cells to cure
Therefore, when you undertake a particular posi- diseases such as diabetes, osteoporosis, and
tion of employment in a health agency, it is your Parkinson’s?
responsibility to learn exactly what you are legally Although there are no easy answers to any of
permitted to do, and to familiarize yourself with these questions, some guidelines are provided by
your exact responsibilities. an ethical code. Most of the national organiza-
tions affiliated with the different health care
5:2 INFORMATION occupations have established ethical codes for
personnel in their respective occupations.
Ethics Although such codes differ slightly, most contain
Legal responsibilities are determined by law. Eth- the same basic principles:
ics are a set of principles relating to what is mor- ♦ Put the saving of life and the promotion of
ally right or wrong. Ethics provide a standard of health above all else.
conduct or code of behavior. This allows a health ♦ Make every effort to keep the patient as com-
care provider to analyze information and make fortable as possible and to preserve life when-
decisions based on what people believe is right ever possible.
and good conduct. Modern health care advances,
however, have created many ethical dilemmas ♦ Respect the patient’s choice to die peacefully
for health care providers. Some of these dilem- and with dignity when all options have been
mas include: discussed with the patient and family and/or
predetermined by advance directives.
♦ Is euthanasia (assisted death) justified in cer-
tain patients? ♦ Treat all patients equally, regardless of race,
religion, social or economic status, sex, or
♦ Should a patient be told that a health care pro- nationality. Bias, prejudice, and discrimina-
vider has AIDS? tion have no place in health care.
♦ Should aborted fetuses be used for research? ♦ Provide care for all individuals to the best of
♦ When should life support be discontinued? your ability.
♦ Do parents have a religious right to refuse a ♦ Maintain a competent level of skill consistent
life-saving blood transfusion for their child? with your particular occupation.
♦ Can a health care facility refuse to provide ♦ Stay informed and up to date, and pursue
expensive treatment such as a bone marrow continuing education as necessary.
transplant if a patient cannot pay for the treat-
ment? ♦ Maintain confidentiality. Confidenti-
ality means that information about the
♦ Who decides whether a 75-year-old patient or patient must remain private and can be shared
a 56-year-old patient gets a single kidney avail- only with other members of the patient’s
able for transplant? health care team. A legal violation can occur if
♦ Should people be allowed to sell organs for a patient suffers personal or financial damage
use in transplants? when confidential information is shared with
112 CHAPTER 5
others, including family members. Informa-

tion obtained from patients should not be
repeated or used for personal gain. Gossiping
about patients is ethically wrong.
♦ Refrain from immoral, unethical, and illegal
practices. If you observe others taking part in
illegal actions, report such actions to the
proper authorities.
♦ Show loyalty to patients, co-workers, and
employers. Avoid negative or derogatory state-
ments, and always express a positive attitude.
♦ Be sincere, honest, and caring. Treat others as
you want to be treated. Show respect and con-
cern for the feelings, dignity, and rights of
others.
When you enter a health occupation, learn
the code of ethics for that occupation. Make every
effort to abide by the code so as to become a com- FIGURE 5-7 Patients have the right to refuse
petent and ethical health care worker. In doing treatment.
so, you will earn the respect and confidence of
patients, co-workers, and employers. ♦ Reasonable response to a request for services
♦ Obtain information regarding any relation-
5:3 INFORMATION ship of the hospital to other health care and
educational institutions
Patients’ Rights ♦ Be advised of and have the right to refuse to
Federal and state legislation requires health participate in any research project
care agencies to have written policies con- ♦ Expect reasonable continuity of care
cerning patients’ rights, or the factors of care
that patients can expect to receive. Agencies
♦ Review medical records and examine bills and
receive an explanation of all care and charges
expect all personnel to respect and honor these
rights. ♦ Be informed of any hospital rules, regulations,
The American Hospital Association has and/or policies and the resources available to
affirmed a Patient’s Bill of Rights that is recog- resolve disputes or grievances
nized and honored by many health care facilities. Residents in long-term care facilities are
This bill of rights states, in part, that a patient has guaranteed certain rights under the Omni-
the right to: bus Budget Reconciliation Act (OBRA) of 1987.
♦ Considerate and respectful care Every long-term care facility must inform resi-
♦ Obtain complete, current information con- dents or their guardians of these rights and a copy
cerning diagnosis, treatment, and prognosis must be posted in each facility. This is often called
(expected outcome) a Resident’s Bill of Rights and states, in part,
that a resident has the right to:
♦ Receive information necessary to give
informed consent prior to the start of any pro- ♦ Free choice regarding physician, treatment,
cedure or treatment care, and participation in research
♦ Have advance directives for health care and/ ♦ Freedom from abuse and chemical or physical
or refuse treatment to the extent permitted restraints
under law (figure 5-7) ♦ Privacy and confidentiality of personal and
♦ Privacy concerning a medical care program clinical records
♦ Confidential treatment of all communications ♦ Accommodation of needs and choice regard-
and records ing activities, schedules, and health care
♦ Voice grievances without fear of retaliation or

discrimination
5:4 INFORMATION
♦ Organize and participate in family/resident Advance Directives
groups and in social, religious, and commu- for Health Care
nity activities
Advance directives for health care, also
♦ Information on medical benefits, medical known as legal directives, are legal docu-
records, survey results, deficiencies of the facil- ments that allow individuals to state what medi-
ity, and advocacy groups including the ombuds- cal treatment they want or do not want in the
man program (state representative who checks event that they become incapacitated and are
on resident care and violation of rights) unable to express their wishes regarding medical
♦ Manage personal funds and use personal pos- care. Two main directives are a living will and a
sessions Designation of Health Care Surrogate or a Dura-
ble Power of Attorney (POA) for Health Care.
♦ Unlimited access to immediate family or rela-
Living wills (figure 5-9) are documents that
tives and to share a room with his or her
allow individuals to state what measures should
spouse, if both are residents (figure 5-8)
or should not be taken to prolong life when their
♦ Remain in the facility and not be transferred conditions are terminal (death is expected). The
or discharged except for medical reasons, the document must be signed when the individual is
welfare of the resident or others, failure to pay, competent and witnessed by two adults who can-
or if the facility either cannot meet the resi- not benefit from the death. Most states now have
dent’s needs or ceases to operate laws that allow the withholding of life-sustaining
All states have adopted these rights, and some procedures and that honor living wills. A living
have added additional rights. It is important to will frequently results in a Do Not Resuscitate
check state law and obtain a list of rights estab- (DNR) order for a terminally ill individual. The
lished in your state. Health care workers can face DNR order means that cardiopulmonary resusci-
job loss, fines, and even imprisonment if they do tation is not performed when the patient stops
not follow and grant established patients’ or resi- breathing. The patient is allowed to die with
dents’ rights. By observing these rights, the health peace and dignity. At times this is extremely dif-
care worker helps ensure the patient’s safety, pri- ficult for health care workers to honor. It is impor-
vacy, and well-being, and provides quality care at tant to remember that many individuals believe
all times. that the quality of life is important and a life on
support systems has no meaning or purpose for
them.
A Designation of Health Care Surrogate,
also called a Durable Power of Attorney (POA)
for Health Care, is a document that permits an
individual (known as a principal) to appoint
another person (known as an agent) to make any
decisions regarding health care if the principal
should become unable to make decisions (figure
5-10). This includes providing or withholding
specific medical or surgical procedures, hiring or
dismissing health care providers, spending or
withholding funds for health care, and having
access to medical records. Although they are most
frequently given to spouses or adult children,
POAs can be given to any qualified adult. To meet
legal requirements, the POA must be signed by
the principal, agent, and one or two adult wit-
FIGURE 5-8 A married couple in a long-term care nesses.
facility has the legal right to share a room if both A federal law, called the Patient Self-Deter-
members of the couple are residents in the facility. mination Act (PSDA) of 1990, mandates that all
114 CHAPTER 5
FLORIDA LIVING WILL – PAGE 1 OF 2

INSTRUCTIONS
PRINT THE DATE Declaration made this _______ __ day of _________________, ________,
(day) (month) (year)
PRINT YOUR NAME I, _____________________________________________________,

willfully and voluntarily make known my desire that my dying not be
artificially prolonged under the circumstances set forth below, and I do
hereby declare that :
PLEASE INITIAL If at any time I am incapacitated and

EACH THAT APPLIES
______ I have a terminal condition, or
______ I have an end-stage condition, or
______ I am in a persistent vegetative state
and if my attending or treating physician and another consulting physician
have determined that there is no reasonable medical probability of my
recovery from such condition, I direct that life-prolonging procedures be
withheld or withdrawn when the application of such procedures would
serve only to prolong artificially the process of dying, and that I be
permitted to die naturally with only the administration of medication or
the performance of any medical procedure deemed necessary to provide
me with comfort care or to alleviate pain.
It is my intention that this declaration be honored by my family and

physician as the final expression of my legal right to refuse medical or
surgical treatment and to accept the consequences for such refusal. In the
event that I have been determined to be unable to provide express and
informed consent regarding the withholding, withdrawal, or continuation
of life-prolonging procedures, I wish to designate, as my surrogate to
carry out the provision of this declaration:
Name:
__________________________________
PRINT THE NAME,
HOME ADDRESS
AND TELEPHONE Address: __________________________________
NUMBER OF YOUR
SURROGATE _______________________________________ Zip Code: __________________________________
© 2005 National
Phone:
Hospice and __________________________________
Palliative Care
Organization
2006 Revised
FLORIDA LIVING WILL - PAGE 2 OF 2
I wish to designate the following person as my alternate surrogate, to carry

out the provisions of this declaration should my surrogate be unwilling or
unable to act on my behalf:
PRINT NAME, HOME Name: _________________________________

ADDRESS
AND TELEPHONE Address: _________________________________
NUMBER OF YOUR _________________________________ Zip Code: _________________________________
ALTERNATE
SURROGATE
Phone:
_________________________________
ADD PERSONAL Additional instructions (optional):

INSTRUCTIONS
(IF ANY)
SIGN THE I understand the full import of this declaration, and I am emotionally and
DOCUMENT mentally competent to make this declaration.
Signed:
________________________
WITNESSING Witness 1:
PROCEDURE
Signed: ________________________
Address: ________________________
TWO WITNESSES
MUST SIGN AND
PRINT THEIR Witness 2:
ADDRESSES
Signed: ________________________
Address: ________________________
© 2005 National
Hospice and Courtesy of Caring Connections
Palliative Care 1700 Diagonal Road, Suite 625, Alexandria, VA 22314
Organization www.caringinfo. , 800/658-8898
2006 Revised
FIGURE 5-9 A living will is a legal document that FIGURE 5-10 A designation of health care
allows an individual to state what measures should surrogate is a legal document that allows an indi-
or should not be taken to prolong life. (Copyright © vidual to appoint another person to make health
2005 National Hospice and Palliative Care Organi- care decisions if the individual is unable to make his
zation. All rights reserved. Reproduction and or her own decisions. (Copyright © 2005 National
distribution by an organization or organized group Hospice and Palliative Care Organization. All rights
without the written permission of the National reserved. Reproduction and distribution by an
Hospice and Palliative Care Organization is organization or organized group without the written
expressly forbidden. For more information, please permission of the National Hospice and Palliative
visit our Web site at www.caringinfo.org) Care Organization is expressly forbidden. For
more information, please visit our Web site at
www.caringinfo.org)
health care facilities receiving any type of federal ♦ Use approved, correct methods while perform-
aid comply with the following requirements: ing any procedure. Follow specific methods
♦ Inform every adult, both orally and in writing, taught by qualified instructors in educational
of their right under state law to make deci- facilities, or observe and learn procedures
sions concerning medical care, including the from your employer or authorized personnel.
right to refuse treatment and right-to-die Most health care agencies have an approved
options procedure manual that explains the step-by-
step methods for performing tasks. Use this
♦ Provide information and assistance in prepar- manual or read the manufacturer’s instruc-
ing advance directives
tions on specific equipment or supplies.
♦ Document any advance directives on the ♦ Obtain proper authorization before perform-
patient’s record
ing any procedure. In some health careers, you
♦ Provide written statements to implement the will obtain authorization directly from the
patient’s rights in the decision-making pro- doctor, therapist, or individual in charge of a
cess patient’s care. In other careers, you will obtain
♦ Affirm that there will be no discrimination or authorization by checking written orders (fig-
effect on care because of advance directives ure 5-11). In careers where you have neither
access to patients’ records nor direct contact
♦ Educate the staff on the medical and legal with the individuals in charge of care, an
issues of advance directives
immediate supervisor will interpret orders
The PSDA ensures that patients are informed and then direct you to perform procedures.
of their rights and have the opportunity to deter- ♦ Identify the patient. In some health care agen-
mine the care they will receive. cies, patients wear identification bands. If this
All health care workers must be aware of and is the case, check this name band (figure
honor advance or legal directives. In addition, 5-12). In addition, state the patient’s name
health care workers should give serious consider- clearly, repeating it if necessary. For example,
ation to preparing their own advance directives. say “Miss Jones?” followed by “Miss Sandra
Jones?” to be sure you have the correct patient.
5:5 INFORMATION Some health care facilities now use bar codes
on patient identification bands. A scanner is
Professional Standards
Legal responsibilities, ethics, patients’ rights, and
advance directives all help determine the type of
care provided by health care workers. By follow-
ing certain standards at all times, you can protect
yourself, your employer, and the patient. Some of
the basic standards are as follows:
♦ Perform only those procedures for which you
have been trained and are legally permitted to
do. Never perform any procedure unless you
are qualified. The necessary training may be
obtained from an educational facility, from
your employer, or in special classes provided by
an agency. If you are asked to perform any pro-
cedure for which you are not qualified, it is
your responsibility to state that you have not
been trained and to refuse to do it until you
receive the required instruction. If you are not
legally permitted to either perform a procedure
or to sign documents, it is your responsibility to FIGURE 5-11 Obtain proper authorization before
refuse to do so because of legal limitations. performing any procedure on a patient.
116 CHAPTER 5
contained in the records without proper

authorization and patient consent. If you are
reporting specific information about a patient
to your immediate supervisor, ensure that
your conversation cannot be heard by others.
Avoid discussing patients with others at home,
in social situations, in public places, or any-
where outside the agency.
♦ Think before you speak and carefully con-
sider everything you say. Do not reveal
information, such as a blood pressure reading,
to the patient unless you are specifically
instructed to do so.
♦ Treat all patients equally regardless of race,
religion, social or economic status, sex, or
nationality. Provide care for all individuals to
the best of your ability.
♦ Accept no tips or bribes for the care you pro-
FIGURE 5-12 If a name band is present, use it to vide. You receive a salary for your services, and
identify the patient. the care you provide should not be influenced
by the amount of money a patient can afford
used to check the bar code and verify the to pay. A polite refusal, such as “I’m sorry, I am
identification of the patient. not allowed to accept tips,” is usually the best
♦ Obtain the patient’s consent before performing way to handle this situation.
any procedure. Always explain a procedure ♦ If any error occurs or you make a mistake,
briefly or state what you are going to do, and report it immediately to your supervisor. Never
obtain the patient’s consent. It is best to avoid try to hide or ignore an error. Make every
statements such as “May I take your blood effort to correct the situation as soon as pos-
pressure?” because the patient can say “No.” By sible, and take responsibility for your actions.
stating, “The doctor would like me to check ♦ Behave professionally in dress, language, man-
your blood pressure,” you are identifying the ners, and actions. Take pride in your occupa-
procedure and obtaining consent by the tion and in the work you do. Promote a positive
patient’s acceptance and/or lack of objection. attitude at all times.
If a patient refuses to allow you to perform a
procedure, check with your immediate super- Even when standards are followed, errors
visor. Some procedures require written consent leading to legal action sometimes still occur. Lia-
from the patient. Follow the agency policy with bility insurance constitutes an additional form of
regard to such procedures. Never sign your protection in such cases. Many insurance com-
name as a witness to any written consent or panies offer policies at reasonable cost for health
document unless you are authorized to do so. care workers and students. Some companies will
even issue liability protection under a homeown-
♦ Observe all safety precautions. Handle er’s policy or through a liability policy that pro-
equipment carefully. Be alert to all tects the person against all liabilities, not just
aspects of safety to protect the patient. Know those related to occupation.
and follow safety rules and regulations. Be Again, remember that it is your responsibil-
alert to safety hazards in any area and make ity to understand the legal and ethical impli-
every effort to correct or eliminate such haz- cations of your particular health career. Never
ards as quickly as possible. hesitate to ask specific questions or to request
♦ Keep all information confidential. This written policies from your employer. Contact
includes oral and written information. Ensure your state board of health or state board of edu-
that you do not place patient records in any cation to obtain information regarding regula-
area where they can be seen by unauthorized tions and guidelines for your occupation. By
individuals. Do not reveal any information obtaining this information and by following the

Frozen stem cells that cure major diseases?
Stem cells are a major area of research today. Stem cells are important because they can
become any of the specialized cell types needed in the human body. They can turn into
muscle cells in the heart, nerve cells in the brain, or cells that secrete the insulin needed by
a patient with diabetes. The major sources of stem cells are a developing embryo (infant);
adult tissues such as bone marrow, brain, muscle, skin, and liver; and blood from the umbil-
ical cord of a newborn infant.
Scientists the world over are finding ways to grow stem cells and force them to generate
special cells that can be used to treat injury or disease. Early research has proved it is easier
to work with embryonic cells, but this has created ethical dilemmas because it means
embryos are destroyed. However, if adult cells can be harvested and grown, it would be eas-
ier to use an adult’s own cells because they would not be rejected by the body.
Many scientists believe that, eventually, the study of stem cells will help explain how
cells grow and develop. Conditions such as cancer and birth defects are caused by abnormal
cell division. If scientists can learn how the abnormal development occurs, they could find
ways to treat and even prevent the conditions. Major research is directed toward learning
what makes the cells specialize to become a specific type of cell in the body.
Currently, parents have the option of preserving umbilical cord blood for its stem cells.
When their baby is born, blood from the umbilical cord can be collected and stored in liquid
nitrogen. If the child later develops a disease such as cancer and needs stem cells, the cells
can be recovered and used for the transplant. The cost of this procedure still limits its wide-
spread use, but hopefully less expensive methods will be found to maintain this source of
stem cells. Many stem cell transplants have already been performed successfully, and lives
have been saved.
basic standards listed, you will protect yourself, two or more parties. Contracts create obliga-
your employer, and the patient to whom you pro- tions that must be met by all involved individu-
vide health care. als. If a contract is not performed according to
agreement, the contract is breached, and legal
STUDENT: Go to the workbook and complete action can occur.
the assignment sheet for Chapter 5, Legal and Eth- Understanding privileged communications
ical Responsibilities. is another important aspect of legal responsibili-
ties. A health care worker must be aware that all
information given by a patient is confidential and
CHAPTER 5 SUMMARY should not be told to anyone other than mem-
bers of the patient’s health care team without
the written consent of the patient. Health care
All health care workers have legal and ethical records are also privileged communications and
responsibilities that exist to protect the health can be used as legal records in a court of law.
care worker and employer, and to provide for the Ethical responsibilities are based not on law,
safety and well-being of the patient. but rather, on what is morally right or wrong.
Legal responsibilities in health care usually Most health care occupations each have an estab-
involve torts and contracts. Torts are wrongful lished code of ethics that provides a standard of
acts that do not involve contracts. Examples of conduct or code of behavior. Health care workers
torts that can lead to legal action include mal- should make every effort to abide by the codes of
practice, negligence, assault and battery, inva- ethics established for their given professions.
sion of privacy, false imprisonment, abuse, and Health care workers must respect patients’
defamation. A contract is an agreement between rights. Health care agencies have written poli-
118 CHAPTER 5
cies concerning the factors of care that patients care surrogate or durable power of attorney for
can expect to receive. All personnel must respect health care; compare the different forms.
and honor these rights. 7. Patient Self Determination Act of 1990: locate a
Advance directives for health care are legal copy of this act or information on the purposes
documents that allow individuals to state what of this act (Hint: check federal legislation Web
medical treatment they want or do not want in sites).
the event that they become incapacitated. Two
main examples are a living will and a Designa- 8. Insurance: search for different types of liability
tion of Health Care Surrogate or Durable Power insurance for health care providers; determine
of Attorney for Health Care. As a result of a feder- what different policies cover and their cost.
al law called the Patient Self-Determination Act
(PSDA), any health care facility receiving federal
funds must provide patients with information REVIEW QUESTIONS
regarding and assistance in preparing advance
or legal directives. 1. Choose a specific health care profession (i.e.,
Professional standards of care help provide dental hygienist, physical therapist) and create
guidelines for meeting legal responsibilities, eth- a situation where this individual might be
ics, and patients’ rights. Every health care worker subject to legal action for each of the following
should follow these standards at all times. In ad- torts: malpractice, negligence, assault, battery,
dition, all health care workers should know and invasion of privacy, false imprisonment, abuse,
follow the state laws that regulate their respec- and defamation.
tive occupations.
2. Differentiate between slander and libel.
3. What is the difference between an implied
INTERNET SEARCHES contract and an expressed contract?
Use the suggested search engines in Chapter 12:4 4. You are employed as a geriatric assistant. A
of this textbook to search the Internet for addi- resident tells you that he is saving sleeping pills
tional information on the following topics: so he can commit suicide. He has terminal
cancer and is in a great deal of pain. What
1. Torts: search for additional information or
should you do? Why?
actual legal cases involving malpractice,
negligence, assault and battery, invasion of 5. What is HIPAA? Identify three (3) specific ways
privacy, false imprisonment, and defamation. that HIPAA protects the privacy and confiden-
tiality of health care information.
2. Abuse: research domestic violence or abuse,
child abuse, and elder abuse to determine how 6. Obtain at least two different codes of ethics for
victims might react, signs and symptoms indic- health professions by contacting professional
ative of abuse, and information on how to help organizations or searching the Internet.
these victims. Compare the codes of ethics.
3. Contracts: search for information on compo- 7. Mr. Gonzales is a healthy 55-year-old man with
nents of a contract and legal cases in health a living will that contains a DNR (Do Not
care caused by a breach of contract. Resuscitate) order for terminal conditions. He
goes into cardiac arrest as a result of an allergic
4. Ethics: use Internet addresses for professional
reaction to an injection of dye for a laboratory
organizations (see Chapter 3) to find two or
test. Should cardiopulmonary resuscitation
three different codes of ethics; compare and
(CPR) be started? Why or why not?
contrast the codes of ethics.
8. How does a living will differ from a Designation
5. Patient’s rights: search for complete copies of a
of Health Care Surrogate?
patient’s or resident’s bill of rights; compare
and contrast the different bills of rights (Hint: 9. List five (5) different patient or resident rights.
check American Hospital Association Web site).
10. Identify six (6) professional standards by
6. Advance directives: search for different examples explaining why they are important to meet legal
of a living will and/or a designation of health responsibilities, ethics, and/or patient’s rights.
CHAPTER 6 Medical
Terminology
Chapter Objectives
Observe Standard
Precautions
◆ Identify basic medical abbreviations selected
from a standard list
◆ Define prefixes, suffixes, and word roots
selected from a list of words
◆ Spell and pronounce medical terms correctly
Safety—Proceed with ◆ Define, pronounce, and spell all key terms
Caution
on Federal Law
Math Skill
Science Skill
Career Information
Technology
120 CHAPTER 6
KEY TERMS
abbreviations suffix word roots
prefix
6:1 INFORMATION
lewis & king, md
Using Medical Abbreviations L&K 2501 center street
northborough, oh 12345
As a health care worker, you will see many abbre-

viations. You will be expected to recognize the
most common abbreviations. This section pro- Name Juanita Hansen
vides a basic list of these abbreviations. Address 143 Gregory Lane, Apt. 43 Date 4/7/
Abbreviations are shortened forms of
嗱
words, usually just letters. Common examples
are AM, which means morning, and PM, which Furadantin 50 mg Tabs
means afternoon or evening.
Abbreviations are used in many health fields. #50
Sometimes they are used by themselves. At other Sig 50 mg p.o. qid
times, several abbreviations are combined to give
orders or directions. Consider the following Generic Substitution Allowed Susan Rice M.D.
examples: Dispense As Written
REPETATUR 0 1 2 3 p.r.n. M.D.
BR c– BRP, FFl qh, VS qid ✓LABEL
NPO 8 PM, To Lab for CBC, BUN, and FBS
These examples are short forms for giving FIGURE 6-1 Can you use the list of abbreviations
to interpret the prescription?
directions. The first example is interpreted as fol-
lows: bedrest with bathroom privileges, force flu-
ids every hour, vital signs four times a day. The
second example is interpreted as follows: noth- on Accreditation of Healthcare Facilities has
ing by mouth after eight o’clock in the evening, to adopted an official Do Not Use list containing
the laboratory for a complete blood count, blood abbreviations and symbols that cause problems.
urea nitrogen, and fasting blood sugar. As these Some common examples include:
examples illustrate, it is much easier to write ♦ IU: abbreviation for international unit; can be
using abbreviations than it is to write the corre- mistaken for IV (intravenous) or the number
sponding detailed messages. 10; write out international unit
Look at the sample prescription form shown ♦ qd, qod, qid: abbreviations for every day, every
in figure 6-1. Use the list of abbreviations to deter- other day, and four times a day, respectively;
mine what the prescription says. can be interchanged if written poorly; for
A sample list of abbreviations and symbols example, an every other day order could be
follows. This list contains some of the most com- done four times in one day; write out daily,
monly used abbreviations. Different abbrevia- every other day, or four times a day
tions may be used in different facilities and in
different parts of the country. It is the responsibil- ♦ cc: abbreviation for cubic centimeter; can be
ity of health care workers to learn the meanings read as “u” or “units” if written poorly; write
of the abbreviations used in the agencies where out milliliter or mL clearly because 1 cubic
they are employed. centimeter equals 1 milliliter
Some agencies are prohibiting the use of spe- ♦ Lack of leading zero (.5 mg): decimal point is
cific abbreviations or symbols because they are missed and 10 times the dose is given (5 mg
prone to causing errors. The Joint Commission instead of .5 mg); write 0.5 or 0.X mg
Medical Terminology 121
♦ @ symbol for at; mistaken for the number 2 if aa of each

written poorly; write out “at” Ab abortion
abd abdomen, abdominal
♦ < or >: symbols for less than or greater than; ABG arterial blood gas
can be misinterpreted as the number 7 or let-
ac before meals
ter L; write greater than or less than
ACLS advanced cardiac life support
♦ Apothecary unit symbols such as or –: symbols ACTH adrenocorticotrophic hormone
for dram and ounce; easily mistaken for each AD right ear
other; write dram or ounce or use metric units ADH antidiuretic hormone
Health care workers must use only the abbre- ad lib as desired
viations or symbols approved by the facility in ADL activities of daily living
which they are employed. In addition, extreme adm admission
care must be used while writing abbreviations AED automated external defibrillation
and symbols so they are legible and readily under- AHA American Hospital Association
stood. AIDS acquired immune deficiency
NOTE: In the lists that follow, these abbreviations syndrome
and symbols are included because they are still used am, AM morning, before noon
in some health facilities. However, an asterisk (*) has AMA American Medical Association,
been placed in front of the abbreviation or symbol to against medical advice
alert the user that it is on the Do Not Use list. amal amalgam
NOTE: There is a growing trend toward eliminating amb ambulate, walk
periods from most abbreviations. Although the fol- amt amount
lowing list does not show periods, you may work in ANA American Nurses’ Association
an agency that chooses to use them. When in doubt, ANS autonomic nervous system
follow the policy of your agency. ant anterior
Learn the abbreviations in the following way: AP apical pulse
♦ Use a set of index cards to make a set of flash- approx approximately
cards of the abbreviations found on the abbre- aq, aqua aqueous (water base)
viation list. Print one abbreviation in big letters ARC AIDS-related complex
on each card. Put the abbreviation on the ART accredited records technician
front of the card and the meaning on the back AS left ear
of the card. as tol as tolerated
ASA aspirin (acetylsalicylic acid)
♦ Use the flashcards to study the abbreviations. ASAP as soon as possible
A realistic goal is to learn all abbreviations for ASCVD arteriosclerotic cardiovascular
one letter per week. For example, learn all of disease
the As the first week, all of the Bs the second ASHD arteriosclerotic heart disease
week, all of the Cs the third week, and so on AU both ears
until all are learned. av average
♦ Follow your instructor’s guidelines for tests on AV arteriovenous, atrioventricular
the abbreviations. Many instructors give A&W alive and well
weekly tests. The tests may be cumulative. Ax axilla, axillary, armpit
They may cover the letter of the week plus any
letters learned in previous weeks.
B
A Ba
bacti
barium
bacteriology
*@ at B&B bowel and bladder training
a before BBB bundle branch block
A&D admission and discharge B&C biopsy and conization
A&P anterior and posterior, BE barium enema
anatomy and physiology bid twice a day
122 CHAPTER 6
bil bilateral co, c/o complains of

Bl blood CO carbon monoxide, coronary
Bl Wk blood work occlusion
BM bowel movement CO2 carbon dioxide
BMI body mass index Comp complete, compound
BMR basal metabolic rate cont continued
BP blood pressure COPD chronic obstructive pulmonary
BR bed rest disease
BRP bathroom privileges COTA certified occupational therapy
BS blood sugar assistant
BSA body surface area CP cerebral palsy
BSC, bsc bedside commode CPK creatine phosphokinase (cardiac
BSE breast self-examination enzyme)
BUN blood urea nitrogen CPR cardiopulmonary resuscitation
Bx, bx biopsy CPT current procedure terminology
CRTT certified respiratory therapy
technician
C CS
C&S
central supply or service
culture and sensitivity
°C degrees Celsius (Centigrade) CSF cerebrospinal fluid
c, w/ with CSR central supply room
Ca calcium CST certified surgical technologist
CA cancer CT computerized tomography
cal calorie Cu copper
Cap capsule CVA cerebral vascular accident
CAT computerized axial tomography (stroke)
Cath catheter, catheterize CVD cardiovascular disease
CBC complete blood count Cx cervix, complication, complaint
CBET certified biomedical equipment
technician
CBR
*cc
complete bed rest
cubic centimeter
D
CC chief complaint d day
CCU coronary care unit, critical care D&C dilatation and curettage
unit DA dental assistant
CDA certified dental assistant DAT diet as tolerated
CDC Centers for Disease Control and DC Doctor of Chiropractic
Prevention D/C, dc, disc discontinue, discharge
CEO chief executive officer DDS Doctor of Dental Surgery
CF cystic fibrosis DEA Drug Enforcement Agency
CHD coronary heart disease del delivery
CHF congestive heart failure Dept department
CHO carbohydrate DH dental hygienist
chol cholesterol DHHS Department of Health and
CICU cardiac intensive care unit Human Services
ck check Diff differential white blood cell
Cl chloride or chlorine count
cl liq clear liquids dil dilute, dissolve
cm centimeter DM diabetes mellitus
CMA certified medical assistant DMD Doctor of Dental Medicine
CNP certified nurse practitioner DMS diagnostic medical sonography
CNS central nervous system DNA deoxyribonucleic acid
DNR do not resuscitate FDA Food and Drug

DO Doctor of Osteopathic Medicine Administration
DOA dead on arrival Fe iron
DOB date of birth FF, FFl force fluids
DOD date of death FH family history
DON director of nursing FHR fetal heart rate
DPM Doctor of Podiatric Medicine Fl, fl fluid
DPT diphtheria, pertussis, tetanus FSH follicle-stimulating hormone
Dr doctor ft foot
dr dram, drainage FUO fever of unknown origin
DRG diagnostic related group Fx, Fr fracture
drg, drsg, dsg dressing
D/S dextrose in saline
DSD
DTs
dry sterile dressing
delirium tremors
G
DVM Doctor of Veterinary Medicine GA gastric analysis, general
DW distilled water anesthesia
D/W dextrose in water gal gallon
Dx, dx diagnosis GB gallbladder
Gc gonococcus, gonorrhea
GH growth hormone
E GI
Gm, g
gastrointestinal
gram
ea each gr grain
EBL estimated blood loss gt, gtt, gtts drop, drops
ECG, EKG electrocardiogram GTT glucose tolerance test
ED emergency department GU genitourinary
EEG electroencephalogram Gyn gynecology
EENT ear, eye, nose, throat
elix elixir
EMG
EMS
electromyogram
emergency medical services
H
EMT emergency medical technician H hydrogen
ENT ear, nose, throat H&H hemoglobin and hematocrit
EPA Environmental Protection H2O water
Agency H2O2 hydrogen peroxide
ER emergency room H, (h), hypo hypodermic injection
ESR erythrocyte sedimentation rate HA hearing aid, headache
et, etiol etiology (cause of disease) HBP high blood pressure
Ex, exam examination HBV hepatitis B virus
Exc excision HCG human chorionic gonadotrophin
Exp exploratory, expiration hormone
ext extract, extraction, external HCl hydrochloric acid
hct hematocrit
HCV hepatitis C virus
F HDL high-density lipoproteins
(healthy type of cholesterol)
°F degrees Fahrenheit Hg mercury
FAS fetal alcohol syndrome Hgb, Hb hemoglobin
FBS fasting blood sugar HHA home health assistant/aide
FBW fasting blood work HIPAA Health Insurance Portability and
FC Foley catheter Accountability Act
124 CHAPTER 6
HIV human immunodeficiency virus Kg, kg kilogram

(AIDS virus) KUB kidney, ureter, bladder X-ray
HMO health maintenance organization
HOB head of bed
HOH
H&P
hard of hearing
history and physical
L
Hr, hr, H, h hour, hours L lumbar
HRT hormone replacement therapy L&D labor and delivery
HS hour of sleep (bedtime) L&W living and well
Ht height (L), lt, lft left
Hx, hx history L, l liter (1,000 cc)
hypo hypodermic injection Lab laboratory
Hyst hysterectomy Lap laparotomy
lat lateral
lb pound
I LCT
LDH
long-term care
lactose dehydrogenase (cardiac
I&D incision and drainage enzyme)
I&O intake and output LDL low-density lipoprotein
ICCU intensive coronary care unit (unhealthy type of cholesterol)
ICD international classification of lg large
diseases liq liquid
ICU intensive care unit LLQ left lower quadrant
ID intradermal, infectious disease LMP last menstrual period
IDDM insulin-dependent diabetes LOC laxative of choice, level of
mellitus consciousness
IH infectious hepatitis LP lumbar puncture
IM intramuscular LPN licensed practical nurse
imp impression LS lumbar sacral
in inch LTC long-term care
inf infusion, inferior, infection LUQ left upper quadrant
ing inguinal LVN licensed vocational nurse
inj injection
int internal, interior
IPPB intermittent positive pressure
breathing
M
irr, irrig irrigation m minim
Isol, isol isolation MA medical assistant
IT inhalation therapy Mat maternity
IUD intrauterine device mcg microgram
IV intravenous MD Medical Doctor, muscular
IVP intravenous pyelogram dystrophy, myocardial disease
Med medical, medicine
mEq milliequivalent
J mg
Mg
milligram
magnesium
jt joint MI myocardial infarction (heart
attack)
MICU medical intensive care unit
K min
mL, ml
minute
milliliter
K potassium MLT medical laboratory technician
KCl potassium chloride mm millimeter
MN midnight OOB out of bed

mod moderate OP outpatient
MOM milk of magnesia OPD, OPC outpatient department or clinic
MRI magnetic resonance imaging opp opposite
MS multiple sclerosis, mitral OR operating room
stenosis, muscular–skeletal Ord orderly
MT medical technologist Orth orthopedics
os mouth
OS left eye, occular sinistra
N OSHA Occupational Safety and Health
Administration
N nitrogen OT occupational therapy/therapist
N/A not applicable OTC over the counter
Na sodium OU each eye
NA nurse aide/assistant OV office visit
NaCl sodium chloride (salt) oz ounce
NB newborn
N/C no complaints
neg
Neur
negative, none
neurology
P
NG, ng, N/G nasogastric tube p after
NICU neurological intensive care unit P pulse, phosphorus
NIDDM non-insulin-dependent diabetes PA physician’s assistant
mellitus PAC premature atrial contraction
NIH National Institutes of Health PAP Papanicolaou test (smear)
nil none para number of pregnancies
NKA no known allergies Path pathology
NKDA no known drug allergies Pb lead
no number PBI protein-bound iodine
NO nursing office pc after meals
noc, noct at night, night PCA patient-controlled analgesia
NP nurse practitioner PCC poison control center
NPN nonprotein nitrogen PCP patient care plan
NPO nothing by mouth PCT patient/personal care technician
N/S, NS normal saline PDR Physicians’ Desk Reference
Nsy nursery PE physical examination,
N/V, N&V nausea and vomiting pulmonary edema
NVD nausea, vomiting, diarrhea Peds pediatrics
NVS neurological vital signs per by, through
PET positron emission tomography
pH measure of acidity/alkalinity
O Pharm
PI
pharmacy
present illness
O2 oxygen PID pelvic inflammatory disease
O&P ova and parasites PKU phenylketonuria
Ob, Obs obstetrics PM, pm after noon
OBRA Omnibus Budget Reconciliation PMC postmortem (after death) care
Act PMS premenstrual syndrome
od overdose PNS peripheral nervous system
OD right eye, occular dextra, Doctor po by mouth
of Optometry PO phone order
oint ointment post posterior, after
OJ orange juice post-op after an operation
126 CHAPTER 6
PP postpartum (after delivery) RT respiratory therapy/therapist

PPE personal protective equipment RUQ right upper quadrant
PPO preferred provider organization Rx prescription, take, treatment
pre-op before an operation
prep prepare
prn
Psy
whenever necessary, as needed
psychology, psychiatry
S
pt patient, pint (500 mL or cc) S sacral
Pt prothrombin time S&A sugar and acetone
PT physical therapy/therapist s, w/o without
PTT partial thromboplastin time SA sinoatrial
PVC premature ventricular sc, SC subcutaneous
contraction SGOT, SGPT transaminase test
PVD peripheral vascular disease SICU surgical intensive care unit
Px prognosis, physical examination SIDS sudden infant death syndrome
Sig give the following directions
sm small
Q SOB
sol
short of breath
solution
q, q every sos if necessary
*qd every day spec specimen
qh every hour SpGr, spgr specific gravity
q2h every 2 hours SPN student practical nurse
q3h every 3 hours spt spirits, liquor
q4h every 4 hours ss one half
qhs every night at bedtime S/S, S&S signs and symptoms
*qid four times a day SSE soap solution enema
qns quantity not sufficient staph staphylococcus infection
*qod every other day stat immediately, at once
qol quality of life STD sexually transmitted disease
qs quantity sufficient STH somatotropic hormone
qt quart strep streptococcus infection
supp suppository
Surg surgery, surgical
R susp
Sx
suspension
symptom, sign
R respiration, rectal syp syrup
®, Rt right
Ra radium
RBC
RDA
red blood cell
recommended daily allowance
T
REM rapid eye movement T&A tonsillectomy and
RHD rheumatic heart disease adenoidectomy
RLQ right lower quadrant T, Temp temperature
RN registered nurse tab tablet
RNA ribonucleic acid TB tuberculosis
R/O rule out tbsp tablespoon
RO reality orientation TCDB turn, cough, deep breathe
ROM range of motion TH thyroid hormone
RR recovery room TIA transient ischemic attack
RRT registered respiratory therapist, tid three times a day
registered radiologic technologist TLC tender loving care
TO telephone order
tol tolerated Y
TPN total parenteral nutrition
y/o years old
TPR temperature, pulse, respiration
YOB year of birth
tr, tinct tincture
yr year
TSH thyroid-stimulating hormone
tsp teaspoon
TUR
TWE
transurethral resection
tap water enema Z
tx traction, treatment, transplant Zn zinc
U MISCELLANEOUS
UA, U/A urinalysis SYMBOLS
ung ointment
Ur, ur urine *⬎ greater than
URI upper respiratory infection *⬍ less than
UTI urinary tract infection ↑ higher, elevate, or up
UV ultraviolet ↓ lower or down
# pound or number
* dram
*–
V ⬘
ounce
foot or minute
Vag vaginal ⬙ inch or second
VD venereal disease º degree
VDM Veterinarian Degree of Medicine 乆 or F female
VDRL serology for syphilis, Venereal 么 or M male
Disease Research Laboratory I or i or Ṫ one
VO verbal order II or ii or ṪṪ two
Vol volume V five
vp venipuncture, venous pressure X ten
VS vital signs (TPR & BP) L fifty
C one hundred
D five hundred
W M one thousand
WBC white blood cell STUDENT: Go to the workbook and complete

WC ward clerk/secretary the assignment and evaluation sheets for 6:1,
w/c wheelchair Using Medical Abbreviations.
WHO World Health Organization
WNL within normal limits
w/o, wo without 6:2 INFORMATION
W/P whirlpool
wt weight
Interpreting Word Parts
Medical dictionaries have been written to include
the many words used in health occupations. It
X would be impossible to memorize all such words.
By breaking the words into parts, however, it is
x times (2x means do 2 times) sometimes possible to figure out their meanings.
x-match cross-match This section provides basic information on doing
XR X-ray just that.
128 CHAPTER 6
A word is often a combination of different meaning enlarged, the vowel o is added for hepa-
parts. The parts include prefixes, suffixes, and tomegaly.
word roots (see figure 6-2). By learning basic prefixes, suffixes, and word
A prefix can be defined as a syllable or word roots, you will frequently be able to interpret the
placed at the beginning of a word. A suffix can be meaning of a word even when you have never
defined as a syllable or word placed at the end of before encountered the word. A list of common
the word. prefixes, suffixes, and word roots follows. An
The meanings of prefixes and suffixes are set. example of a medical term using the word part
For example, the suffix itis means “inflammation and the meaning of the medical term is also pro-
of.” Tonsillitis means “an inflammation of the vided. In addition, the prefixes, suffixes, and word
tonsils,” and appendicitis means “an inflamma- roots for parts of the human body are shown in
tion of the appendix.” Note that the meaning of figure 6-3.
the suffix is usually placed first when the word is Learn the prefixes, suffixes, and word roots in
defined. the following way:
Word roots can be defined as main words or
parts to which prefixes and suffixes can be added. ♦ Use a set of index cards to make flashcards of
In the example appendicitis, the word root is the word parts found on the prefix, suffix, and
appendix. By adding the prefix pseudo-, which word root list. Place one prefix, suffix, or word
means “false,” and the suffix itis, which means root on each card. Put the word part on the
“inflammation of,” the word becomes pseudoap- front of the card and the meaning of the word
pendicitis. This is interpreted as a “false inflam- part on the back of the card. Ensure that each
mation of the appendix.” is spelled correctly.
The prefix usually serves to further define the
word root. The suffix usually describes what is ♦ Use the flashcards to learn the meanings of
happening to the word root. the word parts. A realistic goal is to learn one
When prefixes, suffixes, and/or word roots letter per week. For example, learn all word
are joined together, vowels are frequently added. parts starting with the letter A the first week,
Common examples include a, e, i, ia, io, o, and u. all of those starting with B the second week, all
These are listed in parentheses in the lists that of those starting with C the third week, and so
follow. The vowels are not used if the word root or on until all are learned. Practice correct spell-
suffix begins with a vowel. For example, encephal ing of all of the word parts.
(o) means brain. When it is combined with itis ♦ Follow your instructor’s guidelines for tests
meaning inflammation of, the vowel is not used on the word parts. Many instructors give
for encephalitis. When it is combined with gram, weekly tests. The tests may be cumulative.
meaning tracing or record, the vowel o is added They may cover the letter of the week plus
for encephalogram. Hepat (o) means liver. When any letters learned in previous weeks. Words
it is combined with itis, the vowel is not used for may be presented that use the various word
hepatitis. When it is combined with megaly, parts.
FIGURE 6-2 Prefixes, suffixes, and word roots can be used to interpret the meaning of a word.
head (cephal/o)
skull (crani/o)
(ophthalm/o; ocul/o) eye
brain (cerebr/o; encephal/o)
(blephar/o) eyelid
(nas/o; rhin/o) nose
spinal cord (myel/o)
(or/o; stomat/o) mouth
neck (cervic/o)
(pharyng/o) throat
(esophag/o) esophagus
thyroid gland (thyroid/o)
joint (arthr/o)
(trache/o) windpipe; trachea
(pneum/o; pneumon/o) lung bone (oste/o)
(thorac/o) chest rib cross section (cost/o)

(card/io) heart armpit (axill/o)
(my/o; muscul/o) muscle
(cholecyst/o) gallbladder spleen (splen/o)
(phren/o) diaphragm stomach (gastr/o)

(hepat/o) liver pancreas (pancreat/o)
(col/o) large intestine fat (adip/o; lip/o; steat/o)
(enter/o) small intestine
(appendic/o) vermiform appendix

rectum (rect/o; proct/o)
urinary bladder (cyst/o)

(derm/o; dermat/o) skin
FIGURE 6-3 The prefixes, suffixes, and word roots for parts of the human body.
130 CHAPTER 6
Word Part Meaning Medical Term Meaning
A
a-, an- without, lack of a/pnea without or lack of breathing
ab- from, away ab/duct to move away from the body
-ac, -ic pertaining to cardi/ac pertaining to the heart
acr- (o) extremities (arms and legs) acro/cyan/osis condition of blueness of the extremities
ad- to, toward, near ad/duct to move toward the body
aden- (o) gland, glandular adeno/cele a tumor of a gland
adren- (o) adrenal gland adreno/pathy disease of the adrenal gland
aer- (o) air aero/cele a cavity or pouch swollen with gas or air
-al like, similar, pertaining to neur/al pertaining to a nerve
alba-, albi- white albi/no an organism deficient in pigment, white
alges- (i, ia) pain algesi/meter instrument for measuring pain
-algia pain my/algia muscle pain
ambi- both, both sides ambi/lateral both sides
an- (o, us) anus (opening to rectum) ano/scope an instrument for examining the anus and
rectum
angi- (o) vessel angio/pathy disease of blood vessels
ankyl- crooked, looped, immovable, fixed ankyl/osis stiffness or fixation of a joint
ante- (ro) before, in front of, ahead of ante/partum before labor or childbirth
anti- against anti/bacterial against bacteria
append- (i, o) appendix append/ectomy surgical removal of the appendix
arter- (io) artery aterio/gram tracing or picture of the arteries
arthr- (o) joint arthr/itis inflammation of a joint
-ase enzyme peptid/ase an enzyme that aids in the digestion of
proteins
-asis condition of chole/lithi/asis condition of stones in the gallbladder
-asthenia weakness, lack of strength my/asthenia weakness in a muscle
ather- (o) fatty, lipid athero/sclerosis a fatty hardening
audi- (o) sound, hearing audio/meter an instrument to measure sound or hearing
aur- ear aur/al pertaining to the ear
auto- self auto/phobia a fear of being by oneself or alone
B
bi- (s) twice, double, both bi/lateral two sides
bio- life bio/logy study of science of life
-blast germ/embryonic cell hemo/cyto/blast an embryonic or stem cell for blood cells
blephar- (o) eyelid blepharo/plasty plastic surgery on an eyelid
brachi- arm brachi/algia arm pain
brachy- short brachy/dactyl/ic condition of having short fingers
brady- slow brady/cardia slow heart
bronch- (i, o) air tubes in lungs bronch/itis inflammation of the air tubes in the lungs
bucc- (a, o) cheek bucco/lingu/al pertaining to the cheek and tongue
C
calc- (u, ulus) stone calcul/osis condition of having a stone
carcin- (o) cancer, malignancy carcin/oma cancerous tumor
cardi- (a, o) pertaining to heart cardi/ologist physician who studies and treats heart
disease
carp- (o) wrist carp/itis inflammation of the wrist

-cele, -coele swelling, tumor, cavity, hernia meningo/cele swelling or tumor of the membranes of the
brain and spinal cord
cent- (i) one hundred centi/meter hundred part of a meter (unit of
measurement)
-centesis surgical puncture to remove fluid thora/centesis surgical puncture to remove fluid from the
chest
cephal- (o) head, pertaining to head cephal/algia pain in the head, headache
cerebro- brain cerebro/spin/al pertaining to the brain and spinal cord
cerv- (ic, io) neck, neck of uterus cervio/facial relating to the neck and face
cheil- (o) lip cheilo/plasty plastic surgery to repair lip defects
chem- (o) drug, chemical chemo/therapy treatment with drugs or chemicals
chlor- (o) green chlor/opsia a visual defect in which all objects appear
green
chol- (e, o) bile, gallbladder chole/cyst/ic pertaining to the gallbladder or bag
chond- (i, r, ri) cartilage chondr/itis inflammation of cartilage
chrom- (a, at, o) color chromato/meter an instrument for measuring color
perception
-cide causing death germi/cide causing death to germs
circum- around, about circum/duction movement in a circular motion
-cise cut ex/cise cut out
co- (n) with, together co/chromato/graphy identifying a substance by comparing color
hues with a known substance
-coccus round strepto/coccus round germ causing strep infection
col- (in, o) colon, bowel, large intestine col/ostomy creating an opening into the colon or large
intestine
colp- (i, o) vagina colp/orrhaphy surgical repair of the vaginal wall
contra- against, counter contra/stimulant against a stimulant
cost- (a, i, o) rib cost/ectomy surgical removal of a rib
crani- (o) pertaining to the skull crani/otomy cutting into the skull
-crine secrete exo/crine secrete outside of
cryo- cold cryo/therapy treatment with cold
crypt- (o) hidden, obscure crypto/genic obscure or unknown origin
cut- (an) skin cutane/ous pertaining to the skin
cyan- (o) blue cyan/osis condition of blueness
cyst- (i, o) bladder, bag, sac cyst/itis inflammation of the bladder
cyt- (e, o) cell cyt/ology study of cells
D
dacry- (o) tear duct, tear dacryo/cyst/itis inflammation of the lacrimal (tear duct) sac
dactyl- (o) finger, toe dactyl/oscopy the scientific study of fingerprints
dec- (a, i) ten deci/meter tenth part of a meter (unit of
measurement)
dent- (i, o) tooth dent/al pertaining to teeth
derm- (a, at, o) pertaining to skin dermat/itis inflammation of the skin
-desis surgical union or fixation arthro/desis surgical immobilization of a joint to allow
the bones to grow together
dextr- (i, o) to the right dextro/ocular right eye
di- (plo) double, twice diplo/coccus two round circles
dia- through, between, part dia/dermal cutting through the skin
dis- (ti, to) separation, away from dis/infect to separate or free from infection
dors- (i, o) to the back, back dors/al pertaining to the back
132 CHAPTER 6

duoden- (o) duodenum duoden/ectomy surgical removal of all or part of the
duodenum
dys- difficult, painful, bad dys/uria difficult or painful urination
E
e- (c) without e/dentu/lous condition of being without teeth
ec- (ti, to) outside, external ecto/genous capable of developing away from the host
-ectasis expansion, dilation, stretching bronchi/ectasis dilation or expansion of air tubes in lungs
-ectomy surgical removal of tonsil/ectomy surgical removal of the tonsils
electr- (o) electrical electro/cardio/gram recording of electrical activity in the heart
-emesis vomit hemat/emesis vomiting blood
-emia blood glyc/emia sugar in the blood
encephal- (o) brain encephal/itis inflammation of the brain
endo- within, innermost endo/crine secrete within
enter- (i, o) intestine enter/itis inflammation of the intestine
epi- upon, over, upper epi/gastric above the stomach
erythro- red erythro/cyte red (blood) cell
-esis condition of par/esis condition of paralysis
-esthesia sensation, perception, feel an/esthesia without feeling
eu- well, easy, normal eu/pnea normal respiration or breathing
ex- (o) outside of, beyond exo/path/ic disease that originates outside the body
F
faci- face facio/plegia paralysis of the face
-fascia (l) fibrous band myo/fascial muscle fiber
fibr- (a, i, o) fiber, connective tissue fibr/oma tumor of fibrous tissue
fore- in front of fore/arm the front part of the arm
-form having the form of, shape uni/form one shape or form
-fuge driving away, expelling centri/fuge driving away from the center
G
galacto- milk, galactose (milk sugar) galact/orrhea flow of milk
gast- (i, ro) stomach gastr/itis inflammation of the stomach
-genesis development, production, creation fibro/genesis the development of fibrous tissue
-genetic, -genic origin, producing, causing cyto/genic origin of cells
genito- organs of reproduction genito/urinary organs of reproductive and urinary
systems
-genous kind, type exo/genous outside kind or type
geront- (o) old age, elderly geront/ology study of the elderly
gingiv- gums, gingiva gingiv/itis inflammation of the gums
gloss- (o) tongue glosso/graph instrument for recording movements of the
tongue
gluc- (o) sweetness, sugar, glucose gluco/lipid sugar fat
gly- (c, co) sugar glyc/emia sugar in the blood
-gram tracing, picture, record electro/cardio/gram tracing of the electrical activity in the
heart
-graph diagram, instrument for recording electro/cardio/graph instrument for recording electrical activity
in the heart
gyn- (ec, o) woman, female gynec/ology the study of women
H
hem- (a, ato, o) blood hemat/ology study of the blood
hemi- half hemi/plegia paralysis on half of the body
hepat- (o) liver hepat/itis inflammation of the liver
herni- rupture hernio/plasty surgical repair of a rupture
hetero- other, unlike, different hetero/genous different kind or type
hist- (o) tissue hist/ologist person who studies tissue
hom- (eo, o) same, like homeo/stasis maintaining a constant level
hydro- water hydro/therapy water treatment
hyper- excessive, high, over, increased, hyper/tension high blood pressure
more than normal
hypno- sleep hypno/sis process of sleep
hypo- decreased, deficient, low, under, hypo/tension low blood pressure
less than normal
hyster- (o) uterus hyster/ectomy surgical removal of the uterus
I
-ia, -iasis condition of, abnormal/ pneumon/ia abnormal condition of the lung
pathological state
-ic, -ac pertaining to thorac/ic pertaining to the chest
idio- peculiar to an individual, idio/pathic disease arising by itself or from an
self-originating unknown cause
ile- (o, um) ileum ileo/stomy creating an artificial opening into the ileum
infra- beneath, below infra/sonic sound waves below the frequency of the
human ear
inter- between, among inter/costal between the ribs
intra- within, into, inside intra/ven/ous into a vein
-ism condition, theory, state of being albin/ism condition of being white
iso- equal, alike, same iso/chromatic constant or same color
-itis inflammation, inflammation of pharyng/itis inflammation of the throat
K
kerat- (o) cornea of eye kerato/meter instrument to measure the curvature of the
cornea
-kinesis, -kinetic motion dys/kinetic difficult movement
L
labi- (a, o) lip labio/lingual pertaining to the lips and tongue
lacrima- tears lacrima/tion secretion of tears
lact- (o) milk lacto/genesis production of milk
lapar- (o) abdomen, abdominal wall lapar/otomy cutting into the abdomen
laryng- (o) larynx (voicebox) laryng/itis inflammation of the voicebox
latero- (al) side ambi/lateral both sides
-lepsy seizure, convulsion narco/lepsy sleep seizure
leuco-, leuko- white leuko/cyte white (blood) cell
lingu- (a, o) tongue lingu/al pertaining to the tongue
lip- (o) fat, lipids lipo/cyte fat cell
lith- (o) stone, calculus litho/tripsy crushing a stone
-logy study of, science of bio/logy study or science of life
134 CHAPTER 6

lymph- (o) lymph tissue lymph/oma tumor of lymph tissue
-lys (is, o) destruction, dissolving of thrombo/lysis destruction or dissolving of clots
M
macro- large macro/cyte large cell
mal- bad, abnormal, disordered, poor mal/nutrition poor nutrition
malac- (ia) softening of a tissue malac/ia tissue softening
mamm- (o) breast, mammary glands mammo/gram radiographic (X-ray) image of the breast
-mania insanity, mental disorder pyro/mania individual with the insane desire to start
fires
mast- (o) breast masto/pathy disorder of the breast
med- (i, io) middle, midline medio/carpal in the middle of or between the two rows of
carpals (wrist bones)
-megaly, mega- large, enlarged cardio/megaly enlarged heart
melan- (o) black melan/oma black cancer
mening- (o) membranes covering the brain mening/itis inflammation of the membranes of the
and spinal cord brain and spinal cord
meno- monthly, menstruation meno/rrhea monthly flow or discharge
mes- (o) middle, midline meso/cephal/ic condition of having a head of medium
proportions
-meter measuring instrument, measure urino/meter instrument to measure (specific gravity of)
urine
-metry measurement audio/metry measurement of hearing acuity
micro- small micro/scope instrument to examine small things
mono- one, single mono/cyte single cell
-mortem death post/mortem after death
muc- (o, us) mucus, secretion of mucous muco/static stopping the secretion of mucus
membrane
multi- many, much, a large amount multi/para woman who has borne more than one child
my- (o) muscle my/algia muscle pain
myc- (o) fungus myco/cide substance that kills fungus
myel- (o) bone marrow, spinal cord myelo/blast bone marrow cell
myring- (o) eardrum, tympanic membrane myring/otomy cutting into the eardrum
N
narc- (o) sleep, numb, stupor narco/lepsy sleep seizure
nas- (o) nose nas/al pertaining to the nose
-natal birth pre/natal before birth
necr- (o) death necr/osis condition or process of death
neo- new neo/natal newborn (infant)
neph- (r, ro) kidney nephro/lith kidney stone
neur- (o) nerve, nervous system neur/algia nerve pain
noct- (i) night, at night noct/uria urination at night
non- no, none non/toxic not poison
O
ocul- (o) eye oculo/graph machine to measure eye (movement)
odont- (o) tooth odont/algia pain in a tooth, toothache
olig- (o) few, less than normal, small olig/uria less than normal (amounts of) urine
-ologist person who does/studies radi/ologist person who studies radiographs

-ology study of, science of hemat/ology study of blood
-oma tumor, a swelling carcin/oma cancerous tumor
onco- (i) mass, bulk, tumor oncol/ogist physician who studies cancer
oophor- (o) ovary, female egg cell oophor/ectomy surgical removal of the ovaries
ophthalm- (o) eye ophthalmo/scope instrument for examining the eye
-opia vision dipl/opia double vision
-opsy to view aut/opsy view internal organs of a dead person
opt- (ic) vision, eye optic/al pertaining to the eye
or- (o) mouth or/al pertaining to the mouth
orch- (ido) testicle, testes orch/itis inflammation of a testis
-orrhea flow, discharge rhin/orrhea flow or discharge from the nose
orth- (o) normal, straight ortho/dontics branch of dentistry involved with aligning
or straightening the teeth
ost- (e, eo) bone osteo/genesis formation of bone
-oscopy diagnostic examination colon/oscopy diagnostic examination of the colon or
large intestine
-osis condition, state, process necr/osis condition or process of death
ot- (o) ear oto/scope instrument for examining the ear
-otic pertaining to a condition leuko/cyt/otic condition of white blood cells
-otomy cutting into crani/otomy cutting into the skull
-ous full of, containing, pertaining to, ven/ous pertaining to a vein
condition
ovi-, ovario- egg, female sex gland, ovary ovari/ectomy surgical removal of an ovary
P
pan- all, complete, entire pan/ater/itis inflammation of all layers of an artery
pancreat- (o) pancreas pancreat/itis inflammation of the pancreas
para- near, beside, beyond, abnormal, para/plegia paralysis of the lower half of the body
lower half of the body
-paresis paralysis hemi/paresis paralysis on one side of the body
-partum birth, labor post/partum after birth
path- (ia, o, y) disease, abnormal condition path/ology study of disease
ped- (ia) child pedia/tric pertaining to children
-penia lack of, abnormal reduction in erythro/cyto/penia deficiency of red blood cells
number, deficiency
pent- (a) five penta/dactyl having five digits (fingers or toes)
-pepsia, -pepsis digestion dys/pepsia difficult digestion (indigestion)
per- through, by, excessive per/axillary through the axilla or armpit
peri- around peri/cardi/al pertaining to area around the heart
-pexy fixation gastro/pexy surgical operation in which the stomach is
sutured or fixed to the abdominal wall
phag- (o) eat, ingest phago/cyt/osis process of cells engulfing and destroying
microorganisms
-phage, -phagia to eat, consuming, swallow dys/phagia difficult or painful swallowing
pharyng- (o) pharynx, throat pharyng/itis inflammation of the throat or pharynx
-phas, -phasia speech a/phasia without speech
-philia, -philic affinity for, attracted to necro/philia attracted to or unusual interest in death
phleb- (o) vein phleb/otomy cutting into a vein
-phobia fear hydro/phobia fear of water
phon- (o) sound, voice phon/asthenia weakness or hoarseness of the voice
-phylaxis protection, prevention pro/phylaxis for prevention
136 CHAPTER 6

-plasty surgical correction or repair chondro/plasty surgical repair of cartilage
-plegia paralysis hemi/plegia paralysis of half of the body
pleuro- side, rib pleur/itis inflammation of the pleural membranes
lining the side of the thorax
-pnea breathing a/pnea without breathing
pneum- (o, on) lung, pertaining to the lungs, air pneumon/ectomy surgical removal of a lung (or part of a
lung)
pod- (e, o) foot pod/algia foot pain
poly- many, much poly/uria much urine (more than normal amounts)
post- after, behind post/operative after an operation
pre- before, in front of pre/operative before an operation
pro- in front of, forward pro/cephalic in front of the head
proct- (o) rectum, rectal, anus procto/scope instrument for examining the rectum
pseudo- false pseudo/appendic/itis false inflammation of the appendix
psych- (i, o) pertaining to the mind psych/ology study of the mind
-ptosis drooping down, sagging, visero/ptosis drooping down or displacement of internal
downward displacement organs
pulmon- (o) lung pulmon/ary pertaining to the lung
py- (o) pus pyo/genic producing pus
pyel- (o) renal pelvis of kidney pyelo/lith/otomy surgical incision of the renal pelvis to
remove a stone
pyr- (o) heat, fever pyro/genic produced by a fever
Q
quad- (ra, ri) four quadra/plegia paralysis of four extremities (arms and
legs)
R
radi- (o) radiographs (X-rays), radiation radi/ologist person who studies radiographs
rect- (o) rectum recto/cele rupture of the rectum
ren- (o) kidney ren/al pertaining to the kidney
retro- backward, in back, behind retro/lingual occurring behind or near the base of the
tongue
rhin- (o) nose, pertaining to the nose rhino/plasty surgical correction of the nose
-rraphy suture of, sewing up of a gap angio/rraphy sewing (suturing) a gap or defect in a
or defect vessel
-rrhagia sudden or excessive flow rhino/rrhagia sudden flow from the nose (nosebleed)
-rrhea flow, discharge meno/rrhea monthly flow or discharge
-rrhexis rupture of, bursting hystero/rrhexis rupture of the uterus
S
salping- (i, o) tube, fallopian tube salping/ectomy surgical removal of a fallopian tube
sanguin- (o) blood sanguino/purulant containing blood and pus
sarc- (o) malignant (cancer) connective tissue sarc/oma cancerous tumor of connective tissue
-sarcoma tumor, cancer adeno/sarcoma cancerous tumor of a gland
scler- (o) hardening sclero/derma thickening or hardening of the skin
-sclerosis dryness or hardness arterio/sclerosis hardness of an artery
-scope examining instrument oto/scope instrument for examining the ear
-scopy observation procto/scopy examination of the rectum
-sect cut bi/sect to cut into two parts
semi- half, part semi/cartilagin/ous partly of cartilage

sep- (ti, tic) poison, rot, infection septic/emia blood infection
sinistr- (o) left sinistr/ocular left eye
soma- (t, to) body somato/genic originating in the body
son- (o) sound sono/gram an image produced by sound waves
-spasm involuntary contraction myo/spasm contraction of muscle
sperm- (ato) spermatozoa, male germ (sex) cell spermat/uria discharge of sperm in the urine
splen- (o) spleen spleno/megaly abnormal enlargement of the spleen
-stasis stoppage, maintaining a homeo/stasis maintaining the same constant level
constant level
steno- contracted, narrow steno/sis condition of narrowing
stern- (o) sternum, breast bone sterno/cost/al pertaining to the ribs and breastbone
(sternum)
stoma- (t) mouth stomat/ology scientific study of the mouth and its
disorders
-stomy artificial opening colo/stomy creating an opening into the colon or large
intestines
sub- less, under, below sub/lingual under the tongue
sup- (er, ra) above, upon, over, higher supra/thorac/ic pertaining to the area in the upper part of
in position the chest
sym-, syn- joined, fused, together syn/dactyl two or more digits (fingers or toes) joined
together
T
tach- (o, y) rapid, fast tachy/cardia fast or rapid heart
ten- (do, don, o) tendon tendon/itis inflammation of a tendon
tetra- four tetra/paresis weakness or paralysis of all four limbs
-therapy treatment chemo/therapy treatment with drugs or chemicals
therm- (o, y) heat therm/algesia sensitive to heat
thorac- (o) thorax, chest thorac/otomy cutting into the chest
thromb- (o) clot, thrombus thrombo/lysis dissolving or destruction of clots
thym- (o) thymus gland thym/oma tumor of the thymus gland
thyr- (o, oid) thyroid gland thyroid/ologist individual who studies the thyroid gland
-tome instrument that cuts myo/tome instrument for cutting muscle
-tox (ic) poison cyto/toxic cell poison
trach- (e, i, o) trachea, windpipe trache/otomy cutting into the trachea or windpipe
trans- across, over, beyond trans/neural across a nerve
tri- three tri/angle three angles
trich- (o) hair tricho/myo/sis fungus disease of the hair
-trips (y) crushing by rubbing or grinding litho/tripsy crushing of stone
-trophy nutrition, growth, development a/trophy without nutrition (wasting away)
tympan- (o) eardrum, tympanic membrane tympan/itis inflammation of the eardrum (tympanic
membrane)
U
ultra- beyond, excess ultra/sonic beyond sound waves
uni- one uni/ocular one eye
ur- (in, o) urine, urinary tract urino/meter instrument to measure (specific gravity)
urine
ureter- (o) ureter (tube from kidney to bladder) uretero/cele dilation of the ureter into the bladder
138 CHAPTER 6

urethr- (o) urethra (tube from bladder urethro/scope instrument to view the urethra
to urinary meatus)
-uria urine hemat/uria blood in urine
uter- (o) uterus, womb utero/vaginal pertaining to the uterus and vagina
V
vas- (o) vessel, duct vaso/neur/otic pertaining to blood vessels and nerves
ven- (a) vein ven/ous pertaining to vein
ventro- to the front, abdomen ventr/al pertaining to the front
vertebr- (o) spine, vertebrae vertebr/al pertaining to the spine or vertebrae
vesic- (o) urinary bladder vesico/urethral connecting the urinary bladder and urethra
viscer- (o) internal organs viscero/ptosis drooping or displacement of internal
organs
vit- (a) necessary for life vit/al important to life
X
xanth- (o) yellow xantho/derma yellowish discoloration of the skin
-xen (ia, a) strange, abnormal xeno/genetic derived or originating from a foreign
species
Z
zoo- animal zoo/ology study of animals
zymo- enzymes zymo/gram picture or tracing of enzymes

Artificial red blood cells that replace the need for blood transfusions?
Blood is needed for life. Erythrocytes (red blood cells) in the blood carry the oxygen that
is needed by all body cells. The erythrocytes also carry carbon dioxide, a waste product of
the cells, to the lungs so it can be expelled from the body. Without oxygen, body cells will die
in 4 to 6 minutes.
When a person has a hemorrhage and loses a large amount of blood, an immediate
blood transfusion is needed. The blood for the transfusion comes from other individuals
who are willing to donate blood. However, the annual worldwide shortage of blood is esti-
mated to be about 100 million units. Scientists are busy researching the development of
“artificial” blood or some type of blood cell that will carry the oxygen needed by the body.
Already several products have been developed that meet this need. Dr. Thomas Chang is
one researcher who has worked on this problem since the 1960s. He invented microencap-
sulation, a technique that allows a biochemical to be held inside an artificial membrane. His
work has led to the development of a modified hemoglobin called polyhemoglobin. This
substance carries oxygen in the same way hemoglobin on red blood cells carries oxygen.
Clinical trials of the product are currently being conducted. Another product that has been
developed by Alliance Pharmaceutical is Oxygent. Oxygent is a sterile perfluorochemical
solution that can be used with all blood types, has a shelf life of about 2 years, and contains
no human or animal blood. It carries oxygen in the bloodstream and is used in place of a
blood transfusion. Studies on Oxygent are currently being conducted in Europe. There is
little doubt that researchers will eventually find a substitute for blood transfusions.
STUDENT: Go to the workbook and complete cause of the disease, signs and symptoms, and
the assignment and evaluation sheets for 6:2, main forms of treatment.
Interpreting Word Parts. 3. Cancer: combine word parts to create words
ending in oma. Then search for information on
the different types of tumors. Research benign
CHAPTER 6 SUMMARY and malignant tumors and the signs and
symptoms for each. (Hint: locate the Web site
for the American Cancer Society.)
Medical abbreviations and terminology are used
in all health care occupations and facilities. To
communicate effectively, health care workers REVIEW QUESTIONS
must be familiar with common abbreviations
and terminology. 1. Determine the meaning of the abbreviations
Medical abbreviations are shortened forms bid, tid, and qid. Find prefixes that define the
of words, usually just letters. Sometimes, they first letters (b, t, and q) of the three abbrevia-
are used by themselves; other times, several ab- tions. Determining associations similar to
breviations are combined to give orders or di- these will make it easier to learn medical
rections. abbreviations.
Medical terminology consists of the use of
prefixes, suffixes, and word roots to create words. 2. List ten (10) abbreviations for diseases or
Entire dictionaries have been written to include disorders of the body.
the terminology used in health care. It would be 3. List ten (10) abbreviations for diagnostic tests
impossible to memorize the meaning of every such as blood work or radiology (X-ray)
word. By learning common prefixes, suffixes, studies.
and word roots, however, a health care worker
can break a word into parts and figure out the 4. Add the suffix -oma to five different word roots
meaning of the word. for tissues or parts of the body. Check a medi-
cal dictionary to determine whether the
spelling is correct and to learn the full meaning
INTERNET SEARCHES of the word. One example is melanoma.
5. Choose five (5) word roots related to a part of
Use the suggested search engines in Chapter 12:4 the body. Add different prefixes and/or suffixes
of this textbook to search the Internet for addi- to the word root to create at least three differ-
tional information on the following topics: ent terms for each body part. For example:
1. Medical terminology resources: search publish- cystitis, cystoscopy, and cystocele.
ers such as Delmar Cengage Learning, Mosby, 6. A patient is admitted to a hospital with a dx of
or McGraw-Hill, for medical terminology pancreatitis, dysphagia, and gastralgia. Sx
books, videos, and software. Evaluate different include NVD and a severe HA. The dr orders an
methods of learning medical terminology as abd MRI, CBC, NPO except for cl liq, VS q2h,
presented in these resources. and CBR. Interpret all the above medical
2. Diseases: combine word parts to name diseases abbreviations and terms to determine the
or conditions such as cholecystitis. Search for patient’s condition and plan of treatment.
information on the diseases. Research the
CHAPTER 7 Anatomy and
Physiology
Chapter Objectives
Observe Standard
Precautions
◆ Apply the appropriate terminology to major
organs and systems of the human body
◆ Identify the major functions of each body
system
◆ Compare interrelationships of body systems
Safety—Proceed with ◆ Describe basic diseases affecting each of the
Caution body systems
OBRA Requirement—Based NOTE: This chapter is meant to serve as a brief introduction to
on Federal Law anatomy and physiology. For more detailed information, refer to
the references listed in the bibliography at the back of the book.
Math Skill
Science Skill
Career Information
Technology
Anatomy and Physiology 141
KEY TERMS
anatomy genes organ
cell genome organelles
cell membrane Golgi apparatus pathophysiology
centrosome (sen⬘-troh-sohm) (gawl⬘-jee ap-a-rat⬘-us) physiology
chromatin (crow⬘-ma-tin) lysosomes (ly⬘-sah-soms) (fizz-ee-all⬘-oh-gee)
connective tissue meiosis (my-o⬘-sis) pinocytic vesicles
cytoplasm (sy⬘-toe-plaz-um) mitochondria protoplasm
dehydration (my-toe-con⬘-dree-ah) (pro⬘-toe-plaz-um)
edema (eh-dee⬘-mah) mitosis (my-toe⬘-sis) stem cells
endoplasmic reticulum muscle tissue system
(en⬘-doe-plaz-mik re-tik⬘- nerve tissue tissue
you-lum) nucleolus (new⬙-klee-oh⬘-lus) vacuoles
epithelial tissue nucleus
(ep⬘-eh-thiel⬙-e-al tish⬘-u)
♦ Compare the four main types of tissue by

7:1 Basic Structure describing the basic function of each type
of the Human Body ♦ Explain the relationships among cells, tissues,
organs, and systems
Objectives
♦ Define, pronounce, and spell all key terms
After completing this section, you should be able
to:
7:1 INFORMATION
♦ Label a diagram of the main parts of a cell
The human body is often described as an effi-
♦ Describe the basic function of each part of a cient, organized machine. When this machine
cell does not function correctly, disease occurs. Before

NOTE: A basic knowledge of human anatomy and physiology is essential for almost every
health care provider. However, some health careers are related to specific body systems. As
each body system is discussed, examples of related health careers are listed. The following
health career categories require knowledge of the structure and function of the entire human
body and will not be listed in specific body system units.
◆ Athletic Trainer ◆ Medical Assistant ◆ Physician Assistant

◆ Emergency Medical ◆ Medical Illustrator ◆ Physician
Careers ◆ Nursing Careers ◆ Surgical Technologist
◆ Medical Laboratory
◆ Pharmacy Careers
Careers
142 CHAPTER 7
understanding the disease processes, however, brane that contains pores to allow substances
the health worker must first understand the nor- to pass between the nucleus and cytoplasm. It
mal functioning of the body. A basic understand- is often called the “brain” of the cell because it
ing of anatomy and physiology is therefore controls many cell activities and is important
necessary. Anatomy is the study of the form and in the process of mitosis or cell division.
structure of an organism. Physiology is the ♦ Nucleolus: one or more small, round bodies
study of the processes of living organisms, or why located inside the nucleus, and important in
and how they work. Pathophysiology is the cell reproduction. Ribosomes, made of ribo-
study of how disease occurs and the responses of nucleic acid (RNA) and protein, are manufac-
living organisms to disease processes. tured in the nucleolus. The ribosomes move
The basic substance of all life is protoplasm. from the nucleus to the cytoplasm, where they
This material makes up all living things. Although aid in the synthesis (production) of protein.
protoplasm is composed of ordinary elements They can exist freely in the cytoplasm or be
such as carbon, oxygen, hydrogen, sulfur, nitro- attached to the endoplasmic reticulum.
gen, and phosphorus, scientists are unable to
♦ Chromatin: located in the nucleus and made
combine such elements to create that character-
of deoxyribonucleic acid (DNA) and protein.
istic called life.
During cell reproduction, the chromatin con-
denses to form rodlike structures called chro-
mosomes. A human cell has 46 chromosomes
CELLS or 23 pairs. Each chromosome contains
between 30,000 to 45,000 genes, the struc-
Protoplasm forms the basic unit of structure and
tures that carry inherited characteristics. Each
function in all living things: the cell. Cells are
gene has a specific and unique sequence of
microscopic structures that carry on all the func-
approximately 1,000 base pairs of DNA; the
tions of life. They take in food and oxygen; pro-
DNA sequence carries the genetic coding that
duce heat and energy; move and adapt to their
allows for exact duplication of the cell. Because
environment; eliminate wastes; perform special
the DNA sequence on genes is unique for each
functions; and reproduce to create new, identical
individual, it is sometimes used as an identifi-
cells. The human body contains trillions of cells.
cation tool similar to fingerprints, but much
These cells vary in shape and size, and perform
more exact. A genome is the total mass of
many different functions.
genetic instruction humans inherit from their
Most cells have the following basic parts (fig-
parents. It consists of strings of DNA nucleo-
ure 7-1):
tides. Human beings have about three billion
♦ Cell membrane: the outer protective cover- nucleotides in their genome. The order of the
ing of the cell. It is also called the plasma nucleotides on the DNA sequences provides
membrane or plasmalemma. It is semiperme- instructions for the body to build all of its
able; that is, it allows certain substances to parts, everything from permanent structures
enter and leave the cell while preventing the such as teeth and brain cells to short-lived
passage of other substances. substances such as blood and hormones.
♦ Cytoplasm: a semifluid inside the cell but out- ♦ Centrosome: located in the cytoplasm and
side the nucleus. It contains water (70–90 per- near the nucleus. It contains two centrioles.
cent), proteins, lipids (fats), carbohydrates, During mitosis, or cell division, the centrioles
minerals, and salts. It is the site for all chemical separate. Thin cytoplasmic spindle fibers form
reactions that take place in the cell, such as pro- between the centrioles and attach to the chro-
tein synthesis (formation) and cellular respira- mosomes. This creates an even division of the
tion. Organelles, or cell structures that help a chromosomes in the two new cells.
cell to function, are located in the cytoplasm. ♦ Mitochondria: rod-shaped organelles lo-
The main organelles are the nucleus, mitochon- cated throughout the cytoplasm. These are
dria, ribosomes, lysosomes, centrioles, Golgi often called the “furnaces” or “powerhouses”
apparatus, and endoplasmic reticulum. of the cell because they break down carbohy-
♦ Nucleus: a mass in the cytoplasm. It is sepa- drates, proteins, and fats to produce adeno-
rated from the cytoplasm by a nuclear mem- sine triphosphate (ATP), the major energy
Nucleolus
Smooth endoplasmic
reticulum
Mitochondrion
Nucleus
Cell membrane
Pinocytic vessel
Vacuole
Cytoplasm
Ribosomes
Lysosome
Centrioles
Golgi apparatus Chromatin Rough endoplasmic reticulum

FIGURE 7-1 Basic parts of a cell.
source of the cell. A cell can contain just 1 to endoplasmic reticulum contains ribosomes,
more than 1,000 mitochondria, depending on which are the sites for protein synthesis (pro-
how much energy the cell requires. duction). Smooth endoplasmic reticulum
♦ Golgi apparatus: a stack of membrane lay- does not contain ribosomes and is not present
ers located in the cytoplasm. This structure in all cells. It assists with cholesterol synthesis,
produces, stores, and packages secretions for fat metabolism, and detoxification of drugs.
discharge from the cell. Cells of the salivary, ♦ Vacuoles: pouchlike structures found
gastric, and pancreatic glands have large num- throughout the cytoplasm that have a vacuo-
bers of Golgi apparatus. lar membrane with the same structure as the
♦ Endoplasmic reticulum: a fine network of cell membrane. They are filled with a watery
tubular structures located in the cytoplasm. substance, stored food, or waste products.
This network allows for the transport of mate- ♦ Lysosomes: oval or round bodies found
rials into and out of the nucleus, and also aids throughout the cytoplasm. These structures
in the synthesis and storage of proteins. Rough contain digestive enzymes that digest and
144 CHAPTER 7
destroy old cells, bacteria, and foreign materi- Centrosome

Nucleolus
als, an important function of the body’s DNA in nucleus
immune system. Lysosomes also fuse with 1
stored food vacuoles to convert the food to a
form that can be used by the mitochondria to 4
produce ATP (energy).
♦ Pinocytic vesicles: pocketlike folds in the
cell membrane. These folds allow large mole-
cules such as proteins and fats to enter the
cell. When such molecules are inside the cell, DNA molecules
duplicate themselves.
the folds close to form vacuoles or bubbles in
the cytoplasm. When the cell needs energy,
the vesicles fuse with lysosomes to allow the
proteins and fats to be digested and used by Aster
2
the mitochondria to produce ATP (energy). Spindle Chromosomes
Centromere separate.
Centriole
Cell Reproduction Chromatids
Most cells reproduce by dividing into two identical

cells. This process is called mitosis, a form of
asexual reproduction (figure 7-2). Skin cells, blood- 5
forming cells, and intestinal tract cells reproduce
continuously. Muscle cells only reproduce every
Centrioles separate, and a
few years, but muscle tissue can be enlarged with spindle forms between them.
exercise. Some specialized cells, such as nerve cells
in the brain and spinal cord, do not reproduce
after birth. If these cells are damaged or destroyed,
others are not formed to replace them.
3
Prior to mitosis, the chromatin material in the
nucleus condenses to form chromosomes, and an
exact duplicate of each chromosome is made. Two nuclei form as
cell separates.
Each chromosome then consists of two identical
strands, called chromatids, joined together by a
structure called a centromere. When mitosis begins,
the two centrioles in the centrosome move to
opposite ends of the cell. A spindle of threadlike
6
fibers trails from the centrioles. The nuclear mem-
brane disappears, and the pairs of duplicated Duplicated chromosomes line
chromosomes attach to the spindles at the center up along center of spindle.
of the cell. The chromatids then split from their
duplicated halves and move to opposite ends of
the cell. Each end now has 46 chromosomes, or 23
pairs. The cytoplasm divides, and a new cell mem-
brane forms to create two new identical cells.
Sex cells (gametes) divide by a process known
as meiosis. This process uses two separate cell Each new cell has the full
divisions to produce four new cells. When female number of chromosomes.
cells (ova) or male cells (spermatozoa or sperm)
divide by meiosis, the number of chromosomes
is reduced to 23, or one-half the number found in
cells created by mitosis. When an ovum and FIGURE 7-2 Mitosis is a form of asexual repro-
sperm join to create a new life, the zygote, or new duction where a cell divides into two identical cells.
cell, has 46 chromosomes: 23 from the ovum and called dehydration occurs. When there is an
23 from the sperm. Thus, the zygote has 46, or 23 excess amount (too much tissue fluid), a condi-
pairs, of chromosomes, the normal number for tion called edema, or swelling of the tissues,
all body cells except the sex cells. occurs.
Immediately after the ovum and sperm join There are four main groups of tissues: epithe-
to form a zygote, the zygote begins a period of lial, connective, nerve, and muscle (figure 7-3).
rapid mitotic division. Within 4–5 days, the zygote Epithelial tissue covers the surface of the
is a hollow ball-like mass of cells called a blasto- body and is the main tissue in the skin. It forms
cyst. Within this blastocyst are embryonic stem the lining of the intestinal, respiratory, circula-
cells. These stem cells have the ability to trans- tory, and urinary tracts, as well as that of other
form themselves into any of the body’s special- body cavities. Epithelial tissue also forms the
ized cells and perform many different functions. body glands, where it specializes to produce spe-
A controversial area of research is now concen- cific secretions for the body, such as mucus and
trated on these stem cells. Scientists are attempt- digestive juices.
ing to determine whether stem cells can be Connective tissue is the supporting fabric of
transplanted into the body and used to cure dis- organs and other body parts. There are two main
eases such as diabetes mellitus, Parkinson’s, heart classes of connective tissue: soft and hard. One
disease, osteoporosis, arthritis, and spinal cord
injuries. The hope is that the stem cells can be Structure Function
programmed to produce new specialized cells
that can replace a body’s damaged cells and cure
a disease. The controversy arises from the fact
that a 4–5-day embryo, capable of creating a new Control
life, is used to obtain the cells. Right-to-life advo- and
cates are strongly opposed to stem cell research if communicate
the cells are obtained from embryos. Another
source of stem cells is the blood in the discarded Nerve
umbilical cord and placenta of a newborn. Cur-
rently, parents have the option of preserving this
blood for its stem cells. The blood is collected and
frozen in liquid nitrogen. If the child later devel- Secrete
ops a disease for which a stem cell transplant can and
provide a cure, the cells can be harvested from protect
the blood and used for the transplant. The cost of
this procedure limits its use, however. Stem cells Epithelium
also exist in adult tissues, such as bone marrow
and the liver. Adult stem cells, however, do not
have the ability to evolve into every kind of cell;
these stem cells evolve into more cells of their Move
own kind. This controversy will continue as sci- and
entists expand stem cell research. protect
Muscle (cardiac)
TISSUE
Although most cells contain the same basic parts,
cells vary greatly in shape, size, and special func- Support
and
tion. When cells of the same type join together for connect
a common purpose, they form a tissue. Tissues
are 60–99 percent water with various dissolved
Connective tissue
substances. This water is slightly salty in nature
and is called tissue fluid. If there is an insufficient FIGURE 7-3 Four main groups of tissues and their
amount (not enough tissue fluid), a condition functions.
146 CHAPTER 7
type of soft connective tissue is adipose, or fatty, helps form the rigid structure of the human body.
tissue, which stores fat as a food reserve or source Blood and lymph are classified as liquid connec-
of energy, insulates the body, fills the area between tive tissue, or vascular tissue. Blood carries nutri-
tissue fibers, and acts as padding. A second type of ents and oxygen to the body cells and carries
soft connective tissue is fibrous connective tissue, metabolic waste away from cells. Lymph trans-
such as ligaments and tendons, which help hold ports tissue fluid, proteins, fats, and other materi-
body structures together. Hard connective tissue als from the tissues to the circulatory system.
includes cartilage and bone. Cartilage is a tough, Nerve tissue is made up of special cells
elastic material that is found between the bones of called neurons. It controls and coordinates body
the spine and at the end of long bones. It acts as a activities by transmitting messages throughout
shock absorber and allows for flexibility. It is also the body. The nerves, brain, and spinal cord are
found in the nose, ears, and larynx, or “voice box,” composed of nerve tissue.
to provide form or shaping. Bone is similar to car- Muscle tissue produces power and move-
tilage but has calcium salts, nerves, and blood ves- ment by contraction of muscle fibers. There are
sels; it is frequently called osseous tissue. Bone three main kinds of muscle tissue: skeletal, cardiac,
TABLE 7-1 Systems of the Body

SYSTEM FUNCTIONS MAJOR ORGANS/STRUCTURES
Integumentary Protects body from injury, infection, and dehydration; Skin, sweat and oil glands, nails, and hair
helps regulate body temperature; eliminates some
wastes; produces vitamin D
Skeletal Creates framework of body, protects internal organs, Bones and cartilage
produces blood cells, acts as levers for muscles
Muscular Produces movement, protects internal organs, Skeletal, smooth, and cardiac muscles
produces body heat, maintains posture
Nervous Coordinates and controls body activities Nerves, brain, spinal cord
Special Senses Allow body to react to environment by providing Eye, ear, tongue, nose, general sense
sight, hearing, taste, smell, and balance receptors
Circulatory Carries oxygen and nutrients to body cells; carries Heart, blood vessels, blood, spleen
waste products away from cells; helps produce cells
to fight infection
Lymphatic Carries some tissue fluid and wastes to blood, Lymph nodes, lymph vessels, spleen,
assists with fighting infection tonsils, and thymus gland
Respiratory Breathes in oxygen and eliminates carbon dioxide Nose, pharynx, larynx, trachea, bronchi, lungs
Digestive Digests food physically and chemically, transports Mouth, salivary glands, pharynx, esopha-
food, absorbs nutrients, eliminates waste gus, stomach, intestine, liver, gallbladder,
pancreas
Urinary Filters blood to maintain fluid and electrolyte balance Kidneys, ureters, urinary bladder, urethra
in the body, produces and eliminates urine
Endocrine Produces and secretes hormones to regulate body Pituitary, thyroid, parathyroid, adrenal,
processes and thymus glands; pancreas, ovaries, testes
Reproductive Provides for reproduction Male: testes, epididymis, vas deferens,
ejaculatory duct, seminal vesicles, prostate
gland, penis, urethra
Female: ovaries, fallopian tubes, uterus,
vagina, breasts
and visceral (smooth). Skeletal muscle attaches to in succeeding sections) are the integumentary,
the bones and provides for movement of the body. skeletal, muscular, circulatory, lymphatic, ner-
Cardiac muscle causes the heart to beat. Visceral vous, respiratory, digestive, urinary (or excretory),
muscle is present in the walls of the respiratory, endocrine, and reproductive. Their functions and
digestive, urinary tract, and blood vessels. main organs are shown in table 7-1.
In summary, cells combine to form tissues,
tissues combine to form organs, and organs and
ORGANS AND SYSTEMS other body parts combine to form systems. These
systems working together help create the miracle
Two or more tissues joined together to perform a called the human body (figure 7-4).
specific function are called an organ. Examples
of organs include the heart, stomach, and lungs.
Organs and other body parts joined together STUDENT: Go to the workbook and complete
to perform a particular function are called a sys- the assignment sheet for 7:1, Basic Structure of the
tem. The basic systems (discussed in more detail Human Body.
Organism
Human Organism
Organ Systems
Organism Respiratory System
Nervous System
Digestive System
Circulatory System
Integumentary System
Skeletal System
Muscular System
Lymphatic System
Organ System Urinary System
Endocrine System
Reproductive System
Organs
Lung
Brain
Organ
Stomach
Kidney
Tissues
Epithelial Tissue
Nervous Tissue
Muscle Tissue
Tissue
Connective Tissue
Increasing Cells
Complexity Epithelial Cell
Nerve Cell
Muscle Cell
Cell
Organelles
Mitochondrion
Organelle Nucleus
Ribosome
Molecules
Sugars
Molecule C6H12O6 Proteins
Water
Atoms or Ions
Carbon
Hydrogen FIGURE 7-4 The levels of
Oxygen
Atom or Ion Nitrogen
complexity in the human
of an Element organism.
148 CHAPTER 7
7:2 Body Planes,

Directions, and Cavities
Objectives
♦ Label a diagram of the main body cavities
to: ♦ Identify the main organs located in each body
cavity
♦ Label the names of the planes and the direc-
tional terms related to these planes on a dia- ♦ Locate the nine abdominal regions
gram of the three planes of the body ♦ Define, pronounce, and spell all key terms
KEY TERMS
abdominal cavity dorsal pelvic cavity
abdominal regions dorsal cavity posterior
anterior frontal (coronal) plane proximal (prox⬘-ih-mahl)
body cavities inferior spinal cavity
body planes lateral (lat⬘-eh-ral) superior
buccal cavity medial (me⬘-dee-al) thoracic cavity (tho-rass⬘-ik)
caudal (kaw⬘-doll) midsagittal (median) plane transverse plane
cranial (kray⬘-nee-al) (mid-saj⬘-ih-tahl) ventral
cranial cavity nasal cavity ventral cavity
distal orbital cavity
half. Body parts above other parts are termed

7:2 INFORMATION superior, and body parts below other parts are
Because terms such as south and east would be termed inferior. For instance, the knee is supe-
difficult to apply to the human body, other direc- rior to the ankle, but inferior to the hip. Two other
tional terms have been developed. These terms directional terms related to this plane include
are used to describe the relationship of one part cranial, which means body parts located near
of the body to another part. The terms are used the head, and caudal, which means body parts
when the body is in anatomic position. This located near the sacral region of the spinal col-
means the body is facing forward, standing erect, umn (also known as the “tail”).
and holding the arms at the sides with the palms The midsagittal or median plane divides
of the hands facing forward. the body into right and left sides. Body parts close
to the midline, or plane, are called medial, and
body parts away from the midline are called lat-
BODY PLANES eral.
The frontal or coronal plane divides the
Body planes are imaginary lines drawn through body into a front section and a back section.
the body at various parts to separate the body Body parts in front of the plane, or on the front of
into sections. Directional terms are created by the body, are called ventral or anterior. Body
these planes. The three main body planes are the parts on the back of the body are called dorsal or
transverse, midsagittal, and frontal (figure 7-5). posterior.
The transverse plane is a horizontal plane Two other directional terms are proximal
that divides the body into a top half and a bottom and distal. These are used to describe the loca-
Midsagittal plane The ventral cavities are larger than the dor-
Right Left Midline sal cavities. The ventral cavity is separated into
two distinct cavities by the dome-shaped muscle
Lateral (away
from midline) called the diaphragm, which is important for res-
piration (breathing). The thoracic cavity is
Medial (toward
the midline) located in the chest and contains the esophagus,
trachea, bronchi, lungs, heart, and large blood
Proximal vessels. The abdominal cavity, or abdomino-
(closer to Cranial pelvic cavity, is divided into an upper part and a
point of (toward the
head) lower part. The upper abdominal cavity contains
reference)
the stomach, small intestine, most of the large
Superior (above)
intestine, appendix, liver, gallbladder, pancreas,
Distal
(away and spleen. The lower abdominal cavity, or pel-
Transverse plane
from vic cavity, contains the urinary bladder, the
point of reproductive organs, and the last part of the large
reference) Inferior (below)
intestine. The kidneys and adrenal glands are
Caudal technically located outside the abdominal cavity
(toward the tail) because they are behind the peritoneal mem-
brane (peritoneum) that lines the abdominal
cavity. This area is called the retroperitoneal
Posterior/dorsal/
back space.
Three small cavities are the orbital cavity
Frontal plane for the eyes, the nasal cavity for the nose struc-
tures, and the buccal cavity, or mouth, for the
Anterior/ventral/
front
teeth and tongue.
FIGURE 7-5 Body planes and directional terms.

ABDOMINAL REGIONS
The abdominal cavity is so large that it is divided
tion of the extremities (arms and legs) in relation into regions or sections. One method of division
to the main trunk of the body, generally called the is into quadrants, or four sections. As shown in
point of reference. Body parts close to the point of figure 7-7, this results in a right upper quadrant
reference are called proximal, and body parts (RUQ), left upper quadrant (LUQ), right lower
distant from the point of reference are called dis- quadrant (RLQ), and left lower quadrant (LLQ). A
tal. For example, in describing the relationship of more precise method of division is into nine
the wrist and elbow to the shoulder (or point of abdominal regions (figure 7-8). The center
reference), the wrist is distal and the elbow is regions are the epigastric (above the stomach),
proximal to the shoulder. umbilical (near the umbilicus or belly button),
and hypogastric, or pelvic (below the stomach).
On either side of the center the regions are the
BODY CAVITIES hypochondriac (below the ribs), lumbar (near the
large bones of the spinal cord), and iliac, or ingui-
Body cavities are spaces within the body that nal (near the groin).
contain vital organs. There are two main body The terms relating to body planes, directions,
cavities: the dorsal, or posterior, cavity and the and cavities are used frequently in the study of
ventral, or anterior, cavity (figure 7-6). human anatomy.
The dorsal cavity is one long, continuous
cavity located on the back of the body. It is divided
into two sections: the cranial cavity, which con- STUDENT: Go to the workbook and complete
tains the brain, and the spinal cavity, which the assignment sheet for 7:2, Body Planes, Direc-
contains the spinal cord. tions, and Cavities.
150 CHAPTER 7
Cranial Orbital cavity

cavity
Nasal cavity
Buccal cavity
Thoracic cavity
Dorsal cavity Spinal
(vertebral
canal) Diaphragm
Ventral cavity
Abdominal cavity
Abdomino-
pelvic cavity
Pelvic cavity
FIGURE 7-6 Body cavities.
Right Left
Umbilicus hypo- Epigastric hypo-
chondriac region chondriac
Right upper Left upper region region
quadrant quadrant
(RUQ) (LUQ)
Right Left
lumbar Umbilical lumbar
region region region
Right lower Left lower
quadrant quadrant
(RLQ) (LLQ)
Right Left
iliac Hypogastric iliac
region region region
FIGURE 7-7 Abdominal quadrants. FIGURE 7-8 Nine abdominal regions.

♦ List six functions of the skin

7:3 Integumentary System
♦ Provide the correct names for three abnormal
Objectives colors of the skin and identify the cause of
After completing this section, you should be able each abnormal color
to: ♦ Describe at least four skin eruptions
♦ Label a diagram of a cross section of the skin ♦ Describe at least four diseases of the integu-
♦ Differentiate between the two types of skin mentary system
glands ♦ Define, pronounce, and spell all key terms
KEY TERMS
albino integumentary system subcutaneous fascia
alopecia (in-teg-u-men⬘-tah-ree) (hypodermis)
constrict (kun-strict⬘) jaundice (jawn⬘-diss) (sub-q-tay⬘-nee-us fash⬘-
crusts macules (mack⬘-youlz) ee-ah)
cyanosis (sy⬘-eh-noh⬘-sis) melanin sudoriferous glands
papules (pap⬘-youlz) (sue-de-rif⬘-eh-rus)
dermis
pustules (pus⬘-tyoulz) ulcer
dilate (die⬘-late)
sebaceous glands vesicles (ves⬘-i-kulz)
epidermis (eh-pih-der⬘-mis)
(seh-bay⬘-shus) wheals
erythema (err-ih-thee⬘-ma)

◆ Allergist ◆ Dermatologist ◆ Plastic Surgeon
7:3 INFORMATION ers are the stratum corneum, the outermost

layer, and the stratum germinativum, the
The integumentary system, or skin, has been innermost layer. The cells of the stratum cor-
called both a membrane, because it covers the neum are constantly shed and replaced by
body, and an organ, because it contains several new cells from the stratum germinativum.
kinds of tissues. Most anatomy courses, however,
♦ Dermis: also called corium, or “true skin.”
refer to it as a system because it has organs and
This layer has a framework of elastic connec-
other parts that work together to perform a par-
tive tissue and contains blood vessels, lymph
ticular function. On an average adult, the skin
vessels, nerves, involuntary muscle, sweat and
covers more than 3,000 square inches of surface
oil glands, and hair follicles. The top of the
area and accounts for about 15 percent of total
dermis is covered with papillae, which fit into
body weight.
ridges on the stratum germinativum of the
Three main layers of tissue make up the skin
epidermis. These ridges form lines, or stria-
(figure 7-9):
tions, on the skin. Because the pattern of
♦ Epidermis: the outermost layer of skin. This ridges is unique to each individual, finger-
layer is actually made of five smaller layers but prints and footprints are often used as meth-
no blood vessels or nerve cells. Two main lay- ods of identification.
152 CHAPTER 7
Sweat pore
Hair shaft
Dermal papilla
Sensory nerve
Stratum ending for touch
corneum
Stratum Epidermis
lucidum
Stratum
Stratum spinosum Dermis
germinativum Stratum
basale
Arrector pili muscle
Sebaceous (oil) gland
Subcutaneous
Hair follicle fatty tissue
(hypodermis)
Papilla of hair
Nerve fiber Vein
Artery
Nerve
Sweat gland
Pacinian corpuscle
FIGURE 7-9 Cross-section of skin.
♦ Subcutaneous fascia or hypodermis: the (which grows in a hollow tube called a follicle)
innermost layer. It is made of elastic and and a hair shaft. Hair helps protect the body and
fibrous connective tissue and adipose (fatty) covers all body surfaces except for the palms of
tissue, and connects the skin to underlying the hands and the soles of the foot. Due to genet-
muscles. ics, male (and some female) individuals may
experience alopecia or baldness, a permanent
The integumentary system has two main loss of hair on the scalp. Nails protect the fingers
types of glands: sudoriferous and sebaceous. The and toes from injury. They are made of dead,
sudoriferous glands (sweat glands) are coiled keratinized epidermal epithelial cells packed
tubes that extend through the dermis and open closely together to form a thick, dense surface.
on the surface of the skin at pores. The sweat, or They are formed in the nail bed. If lost, nails will
perspiration, eliminated by these glands contains regrow if the nail bed is not damaged.
water, salts, and some body wastes. Even though
sweat contains body wastes, it is basically odor-
less. However, when the sweat interacts with bac-
teria on the skin, body odor occurs. The process
of perspiration removes excess water from the
FUNCTIONS
body and cools the body as the sweat evaporates The integumentary system performs the follow-
into the air. The sebaceous glands are oil glands ing important functions:
that usually open onto hair follicles. They pro-
duce sebum, an oil that keeps the skin and hair ♦ Protection: It serves as a barrier to the sun’s
from becoming dry and brittle. Because sebum is ultraviolet rays and the invasion of pathogens,
slightly acidic, it acts as an antibacterial and anti- or germs. It also holds moisture in and pre-
fungal secretion to help prevent infections. When vents deeper tissues from drying out.
an oil gland becomes plugged, the accumulation ♦ Sensory perception: The nerves in the skin help
of dirt and oil results in a blackhead or pimple. the body respond to pain, pressure, tempera-
Two other parts of the integumentary system ture (heat and cold), and touch sensations
are the hair and nails. Each hair consists of a root (figure 7-10).
15 sebaceous
glands
1 yard of
blood vessels
10 hairs
700
sweat
glands
3,000,000
cells 3,000
sensory
cells at
the end
1 square centimeter of nerve
of skin contains: fibers
12 sensory
apparatuses 4 yards
for heat of nerves
2 sensory
apparatuses 25 pressure
for cold apparatus for the
200 nerve perception of tactile
endings stimuli
to record pain
FIGURE 7-10 The nerves in the skin allow the body to respond to many different sensations.
♦ Body temperature regulation: The blood ves-

sels in the skin help the body retain or lose PIGMENTATION
heat. When the blood vessels dilate (get Basic skin color is inherited and is determined by
larger), excess heat from the blood can escape pigments in the epidermis of the skin. A brownish
through the skin. When the blood vessels con- black pigment, melanin, is produced in the epi-
strict (get smaller), the heat is retained in the dermis by specialized cells called melanocytes.
body. The sudoriferous glands also help cool Even though everyone has the same number of
the body through evaporation of perspira- melanocytes, genes present in each racial group
tion. determine the amount of melanin produced. Mel-
♦ Storage: The skin has tissues for temporary anin can lead to a black, brown, or yellow skin tint,
storage of fat, glucose (sugar), water, vitamins, depending on the amount of melanin present and
and salts. Adipose (fatty) tissue in the subcu- racial origin. Ultraviolet light activates the melano-
taneous fascia is a source of energy. cytes to produce more melanin to protect and to
♦ Absorption: Certain substances can be tan the skin. Small concentrated areas of melanin
absorbed through the skin, such as medica- pigment form freckles. Carotene, a yellowish red
tions for motion sickness or heart disease and pigment, also helps determine skin color. A person
nicotine patches to help stop smoking. The with an absence of color pigments is an albino.
medications are placed on sticky patches and An albino’s skin has a pinkish tint and the hair is
applied to the skin. This is called a transder- pale yellow or white. The person’s eyes also lack
mal medication. pigment and are red and very sensitive to light.
Abnormal colors of the skin can indicate dis-
♦ Excretion: The skin helps the body eliminate ease. Erythema is a reddish color of the skin that
salt, a minute amount of waste, and excess can be caused by either burns or a congestion of
water and heat through perspiration. blood in the vessels. Jaundice, a yellow discolor-
♦ Production: The skin helps in the production ation of the skin, can indicate bile in the blood as
of vitamin D by using ultraviolet rays from the a result of liver or gallbladder disease. Jaundice
sun to form an initial molecule of vitamin D also occurs in conjunction with certain diseases
that matures in the liver. that involve the destruction of red blood cells.
154 CHAPTER 7
Cyanosis is a bluish discoloration of the skin and cracks into open sores. Treatment involves
caused by insufficient oxygen. It can be associ- applying an antifungal medication and keeping
ated with heart, lung, and circulatory diseases or the area clean and dry.
disorders. Chronic poisoning may cause a gray or
brown skin discoloration.
Skin Cancer
SKIN ERUPTIONS Cancer of the skin is the most common type of
cancer. There are three main types of skin cancer:
Skin eruptions can also indicate disease. The basal cell carcinoma, squamous cell carcinoma,
most common eruptions include: and melanoma. Basal cell carcinoma is cancer of
the basal cells in the epidermis of the skin. It
♦ Macules: (macular rash) flat spots on the grows slowly and does not usually spread (figure
skin, such as freckles 7-11). The lesions can be pink to yellow-white.
♦ Papules: (papular rash) firm, raised areas They are usually smooth with a depressed center
such as pimples and the eruptions seen in and an elevated, irregular-shaped border.
some stages of chickenpox and syphilis Squamous cell carcinoma affects the thin cells
♦ Vesicles: blisters, or fluid-filled sacs, such as of the epithelium but can spread quickly to other
those seen in chickenpox areas of the body. The lesions start as small, firm,
red, flat sores that later scale and crust (figure
♦ Pustules: pus-filled sacs such as those seen 7-12). Sores that do not heal are frequently squa-
in acne, or pimples mous cell carcinomas.
♦ Crusts: areas of dried pus and blood, com- Melanoma develops in the melanocytes of
monly called scabs the epidermis and is the most dangerous type of
♦ Wheals: itchy, elevated areas with an irregu-
lar shape; hives and insect bites are examples
♦ Ulcer: a deep loss of skin surface that may
extend into the dermis; may cause periodic
bleeding and the formation of scars
DISEASES AND
ABNORMAL CONDITIONS
Acne Vulgaris FIGURE 7-11 Basal cell carcinomas usually grow
more slowly. (Courtesy of Robert A. Silverman, MD,
Acne vulgaris is an inflammation of the seba- Clinical Associate Professor, Department of Pediat-
ceous glands. Although the cause is unknown, rics, Georgetown University)
acne usually occurs at adolescence. Hormonal
changes and increased secretion of sebum are
probably underlying causes. Symptoms include
papules, pustules, and blackheads. These occur
when the hair follicles become blocked with dirt,
cosmetics, excess oil, and/or bacteria. Treatment
methods include frequent, thorough skin wash-
ing; avoidance of creams and heavy makeup;
antibiotic or vitamin A ointments; oral antibiot-
ics; and/or ultraviolet light treatments.
Athlete’s Foot FIGURE 7-12 Squamous cell carcinomas resem-

ble sores that scale and crust. (Courtesy of Robert
Athlete’s foot is a contagious fungal infection that A. Silverman, MD, Clinical Associate Professor,
usually affects the feet. The skin itches, blisters, Department of Pediatrics, Georgetown University)
FIGURE 7-13 Melanoma is the most dangerous

form of skin cancer. (Courtesy of Robert A. Silver-
man, MD, Clinical Associate Professor, Department
of Pediatrics, Georgetown University)
FIGURE 7-14 A contact dermatitis caused by

skin cancer (figure 7-13). The lesions can be contact with poison oak. (Courtesy of Timothy
brown, black, pink, or multicolored. They are Berger, MD, Clinical Professor, Department of
usually flat or raised slightly, asymmetric and Dermatology, University of California, San Fran-
irregular or notched on the edges. cisco)
Frequently, skin cancer develops from a mole
or nevus that changes in color, shape, size, or tex-
ture. Bleeding or itching of a mole can also indi-
cate cancer. Exposure to the sun, prolonged use
of tanning beds, irritating chemicals, or radiation crusts, and scaling. Treatment involves removing
are the usual causes of skin cancer. Treatment the irritant and applying corticosteroids to reduce
involves surgical removal of the cancer, radiation, the inflammatory response.
and/or chemotherapy.
Impetigo
Dermatitis Impetigo is a highly contagious skin infection
Dermatitis, an inflammation of the skin, can be usually caused by streptococci or staphylococci
caused by any substance that irritates the skin. It organisms. Symptoms include erythema, oozing
is frequently an allergic reaction to detergents, vesicles, pustules, and the formation of a yellow
cosmetics, pollen, or certain foods. One example crust. Lesions should be washed with soap and
of contact dermatitis is the irritation caused by water and kept dry. Antibiotics, both topical and
contact with poison ivy, poison sumac, or poison oral, are also used in treatment.
oak (figure 7-14). Symptoms include dry skin, ery-
thema, itching, edema, macular-papular rashes,
and scaling. Treatment is directed at eliminating Psoriasis
the cause, especially in the case of allergens. Anti- Psoriasis is a chronic, noncontagious skin disease
inflammatory ointments, antihistamines, and/or with periods of exacerbations (symptoms pres-
steroids are also used in treatment. ent) and remission (symptoms decrease or disap-
pear). The cause is unknown, but there may be a
hereditary link. Stress, cold weather, sunlight,
Eczema pregnancy, and endocrine changes tend to cause
Eczema is a noncontagious, inflammatory skin an exacerbation of the disease. Symptoms include
disorder caused by an allergen or irritant. Diet, thick, red areas covered with white or silver scales,
cosmetics, soaps, medications, and emotional (figure 7-15). Although there is no cure, treatment
stress can all cause eczema. Symptoms include methods include coal/tar or cortisone ointments,
dryness, erythema, edema, itching, vesicles, ultraviolet light, and/or scale removal.
156 CHAPTER 7
Ringworm
Ringworm (tineas) is a highly contagious fungal
infection of the skin or scalp. The characteristic
symptom is the formation of a flat or raised circu-
lar area with a clear central area surrounded by
an itchy, scaly, or crusty outer ring. Antifungal
medications, both oral and topical, are used in
treatment.
Verrucae
Verrucae, or warts, are caused by a viral infection
of the skin. Plantar warts usually occur at pres-
sure points on the sole of the foot. A rough, hard,
elevated, rounded surface forms on the skin.
Some warts disappear spontaneously, but others
must be removed with electricity, liquid nitrogen,
acid, chemicals, or laser.
FIGURE 7-15 Psoriasis is characterized by white STUDENT: Go to the workbook and complete
or silver scales. (Courtesy of Robert A. Silverman, the assignment sheet for 7:3, Integumentary
MD, Pediatric Dermatology, Georgetown University) System.
♦ Name the two divisions of the skeletal system

7:4 Skeletal System and the main groups of bones in each divi-
Objectives sion

♦ Identify the main bones of the skeleton
to: ♦ Compare the three classifications of joints by
describing the type of motion allowed by
♦ List five functions of bones each
♦ Label the parts of a bone on a diagram of a ♦ Give one example of each joint classification
long bone
♦ Describe at least four diseases of the skeletal
system
KEY TERMS
appendicular skeleton fibula (fib⬘-you-la) metatarsals
(ap-pen-dick⬘-u-lar) fontanels (met-ah-tar⬘-sulz)
axial skeleton foramina (for-ahm⬘-e-nah) os coxae (ahs cock⬘-see)
carpals humerus (hue⬘-mer-us) patella (pa-tell⬘-ah)
clavicles (klav⬘-ih-kulz) joints periosteum
cranium ligaments (per-ee-os⬘-tee-um)
diaphysis (dy-af⬘-eh-sis) medullary canal phalanges (fa-lan⬘-jeez)
endosteum (en-dos⬘-tee-um) (med⬘-hue-lair-ee) radius
epiphysis (ih-pif⬘-eh-sis) metacarpals red marrow
femur (fee⬘-mur) (met-ah-car⬘-pulz) ribs
(continues)
KEY TERMS (continued)

scapula sutures ulna
sinuses (sigh⬘-nuss-ez) tarsals vertebrae (vur⬘-teh-bray)
skeletal system tibia yellow marrow
sternum

◆ Athletic Trainer ◆ Osteopathic Physician ◆ Prosthetist
◆ Chiropractor ◆ Physiatrist ◆ Radiologic Technologist
◆ Orthopedist ◆ Physical Therapist ◆ Sports Medicine Physician
◆ Orthoptist ◆ Podiatrist
or white blood cells. The endosteum is a mem-

7:4 INFORMATION brane that lines the medullary canal and keeps
The skeletal system is made of organs called the yellow marrow intact. It also produces some
bones. An adult human has 206 bones. These bone growth. Red marrow is found in certain
bones work as a system to perform the following bones, such as the vertebrae, ribs, sternum, and
functions: cranium, and in the proximal ends of the humerus
and femur. It produces red blood cells (erythro-
♦ Framework: bones form a framework to sup- cytes), platelets (thrombocytes), and some white
port the body’s muscles, fat, and skin blood cells (leukocytes). Because bone marrow is
♦ Protection: bones surround vital organs to important in the manufacture of blood cells and
protect them (for example the skull, which is involved with the body’s immune response, the
surrounds the brain, and the ribs, which pro- red marrow is used to diagnose blood diseases
tect the heart and lungs) and is sometimes transplanted in people with
defective immune systems. The outside of bone
♦ Levers: muscles attach to bones to help pro- is covered with a tough membrane, called the
vide movement periosteum, which contains blood vessels,
♦ Production of blood cells: bones help produce lymph vessels, and osteoblasts, special cells that
red and white blood cells and platelets, a pro- form new bone tissue. The periosteum is neces-
cess called hemopoiesis or hematopoiesis sary for bone growth, repair, and nutrition. A thin
♦ Storage: bones store most of the calcium sup- layer of articular cartilage covers the epiphysis
ply of the body in addition to phosphorus and and acts as a shock absorber when two bones
fats meet to form a joint.
The skeletal system is divided into two sec-
Bones vary in shape and size depending on tions: the axial skeleton and the appendicular
their locations within the body. Bones of the skeleton. The axial skeleton forms the main
extremities (arms and legs) are called long bones. trunk of the body and is composed of the skull,
The basic parts of these bones are shown in figure spinal column, ribs, and breastbone. The appen-
7-16. The long shaft is called the diaphysis, and dicular skeleton forms the extremities and is
the two extremities, or ends, are each called an composed of the shoulder girdle, arm bones, pel-
epiphysis. The medullary canal is a cavity in vic girdle, and leg bones.
the diaphysis. It is filled with yellow marrow, The skull is composed of the cranial and facial
which is mainly a storage area for fat cells. Yellow bones (figure 7-17). The cranium is the spheri-
marrow also contains cells that form leukocytes, cal structure that surrounds and protects the
158 CHAPTER 7
Articular brain. It is made of eight bones: one frontal, two

cartilage parietal, two temporal, one occipital, one eth-
Proximal
epiphysis moid, and one sphenoid. At birth, the cranium is
Red not solid bone. Spaces called fontanels, or “soft
marrow
spots,” allow for the enlargement of the skull as
Spongy bone brain growth occurs. The fontanels are made of
(contains membrane and cartilage, and turn into solid bone
red marrow)
by approximately 18 months of age. There are 14
facial bones: 1 mandible (lower jaw), 2 maxilla
Medullary cavity (upper jaw), 2 zygomatic (cheek), 2 lacrimal
(contains (inner aspect of eyes), 5 nasal, and 2 palatine
yellow marrow)
(hard palate or roof of the mouth). Sutures are
Artery
areas where the cranial bones have joined
together. Sinuses are air spaces in the bones of
Compact bone tissue
the skull that act as resonating chambers for the
Diaphysis
voice. They are lined with mucous membranes.
Foramina are openings in bones that allow
Endosteum
nerves and blood vessels to enter or leave the
bone.
The spinal column is composed of 26 bones
Yellow called vertebrae (figure 7-18). These bones pro-
marrow tect the spinal cord and provide support for the
head and trunk. They include 7 cervical (neck),
Periosteum 12 thoracic (chest), 5 lumbar (waist), 1 sacrum
(back of pelvic girdle), and 1 coccyx (tailbone).
Pads of cartilage tissue, called intervertebral disks,
separate the vertebrae. The disks act as shock
Distal absorbers and permit bending and twisting
epiphysis movements of the vertebral column.
There are 12 pairs of ribs, or costae. They
FIGURE 7-16 Anatomic parts of a long bone. attach to the thoracic vertebrae on the dorsal sur-
Coronal suture Frontal bone

Parietal bone Sphenoid bone
Squamous suture Ethmoid bone
Nasal bone
Lambdoidal suture
Lacrimal bone
Occipital bone
Maxilla
Zygomatic bone
Temporal bone
External auditory Mandible

meatus
Mastoid process Styloid
of temporal bone process Mental foramen
FIGURE 7-17 Bones of the skull.
C-1 –Atlas Bones of each arm include one humerus

C-2 –Axis (upper arm), one radius (lower arm on thumb
C-3
C-4 Cervical vertebrae side that rotates around the ulna to allow the
C-5 (cervic/o)
C-6 hand to turn freely), one ulna (larger bone of
C-7 lower arm with a projection called the olecranon
T-1
T-2 process at its upper end, forming the elbow), eight
T-3 carpals (wrist), five metacarpals (palm of the
T-4
hand), and fourteen phalanges (three on each
T-5
T-6 finger and two on the thumb).
T-7 Thoracic vertebrae The pelvic girdle is made of two os coxae
T-8 (thorac/o) (coxal, or hip, bones), which join with the sacrum
T-9 on the dorsal part of the body (figure 7-19). On
T-10 the ventral part of the body, the os coxae join
T-11
together at a joint called the symphysis pubis.
T-12
Each os coxae is made of three fused sections: the
L-1
ilium, the ischium, and the pubis. The pelvic gir-
Intervertebral
disk L-2 dle contains two recessed areas, or sockets. These
sockets, called acetabula, provide for the attach-
L-3 Lumbar vertebrae
Vertebral
lumb/o
ment of the smooth rounded head of the femur
body
L-4 (upper leg bone). An opening between the
ischium and pubis, called the obturator foramen,
L-5
allows for the passage of nerves and blood vessels
to and from the legs.
Sacrum
(sacr/o) Each leg consists of one femur (thigh), one
patella (kneecap), one tibia (the larger weight-
Coccyx
(coccyg/o) bearing bone of the lower leg commonly called
the shin bone), one fibula (the slender smaller
FIGURE 7-18 Lateral view of the vertebral, or
spinal, column.
bone of the lower leg that attaches to the proxi-
mal end of the tibia), seven tarsals (ankle), five
metatarsals (instep of foot), and fourteen pha-
langes (two on the great toe and three on each of
the other four toes). The heel is formed by the
face of the body. The first seven pairs are called large tarsal bone called the calcaneous. The bones
true ribs because they attach directly to the ster- of the skeleton are shown in figure 7-20.
num, or breastbone, on the front of the body. The
next five pairs are called false ribs. The first three
pairs of false ribs attach to the cartilage of the rib
above. The last two pairs of false ribs are called
Sacrum
floating ribs because they have no attachment on (sacr/o) Sacroiliac joint
the front of the body. Iliac crest
The sternum, or breastbone, is the last bone (ili/o)
of the axial skeleton. It consists of three parts: the
manubrium (upper region), the gladiolus (body), Anterior
superior
and the xiphoid process (a small piece of carti-
iliac
lage at the bottom). The two collarbones, or clav- spine
icles, are attached to the manubrium by ligaments. Ilium
(ili/o) Coccyx
The ribs are attached to the sternum with costal (coccyg/o)
cartilages to form a “cage” that protects the heart Ischial spine
and lungs. Acetabulum
(ischi/o)
The shoulder, or pectoral, girdle is made of Obturator foramen
Ischium
two clavicles (collarbones) and two scapulas (ischi/o) Symphysis pubis
(shoulder bones). The scapulas provide for (pub/o)
attachment of the upper arm bones. FIGURE 7-19 Anterior view of the pelvic girdle.
160 CHAPTER 7
SKULL Cranium Parietal

Zygomatic
bone Maxilla
Occipital
SHOULDER GIRDLE
Mandible
Clavicle
Acromion process
Scapula
THORAX Scapula
Xiphoid process Sternum
Costal cartilage Ribs
VERTEBRAL
VERTEBRAL UPPER COLUMN
COLUMN EXTREMITY Olecranon
Humerus process
Ilium
Ulna PELVIC
Radius GIRDLE
Sacrum
Carpals
Pubis
Ischium Coccyx
Symphysis
pubis Metacarpals Phalanges
Femur LOWER EXTREMITY Femur
Femur
Patella
Tibia Lateral condyle
Fibula Medial condyle
Tarsals
Metatarsals
Lateral maleolus
Phalanges
Medial maleolus
Calcaneus
FIGURE 7-20 Bones of the skeleton.
Joints ♦ Synarthrosis: immovable; examples are the

suture joints of the cranium
Joints are areas where two or more bones join
together. Connective tissue bands, called liga-
ments, help hold long bones together at joints.
There are three main types of joints: DISEASES AND
♦ Diarthrosis or synovial: freely movable; exam- ABNORMAL CONDITIONS
ples include the ball-and-socket joints of the
shoulder and hip, or the hinge joints of the Arthritis
elbow and knee Arthritis is actually a group of diseases involving
♦ Amphiarthrosis: slightly movable; examples inflammation of the joints. Two main types are
include the attachment of the ribs to the tho- osteoarthritis and rheumatoid arthritis. Osteoar-
racic vertebrae and the symphysis pubis, or thritis, the most common form, is a chronic dis-
joint between the two pelvic bones ease that usually occurs as a result of aging. It
frequently affects the hips and knees. Symptoms Fractures

include joint pain, stiffness, aching, and limited
range of motion. Although there is no cure, rest, A fracture is a crack or break in a bone. Types of
applications of heat and cold, aspirin and anti- fractures, shown in figure 7-22, include:
inflammatory medications, injection of steroids ♦ Greenstick: bone is bent and splits, causing a
into the joints, and special exercises are used to crack or incomplete break; common in chil-
relieve the symptoms. Rheumatoid arthritis is a dren
chronic inflammatory disease that affects the
♦ Simple or closed: complete break of the bone
connective tissues and joints. It is three times
with no damage to the skin
more common in women than in men, and onset
often occurs between the ages of 35 and 45. Pro- ♦ Compound or open: bone breaks and ruptures
gressive attacks can cause scar tissue formation through the skin; creates an increased chance
and atrophy of bone and muscle tissue, which of infection
result in permanent deformity and immobility ♦ Impacted: broken bone ends jam into each
(figure 7-21). Early treatment is important to other
reduce pain and limit damage to joints. Rest, pre-
♦ Comminuted: bone fragments or splinters into
scribed exercise, anti-inflammatory medications
more than two pieces
such as aspirin, and careful use of steroids are the
main forms of treatment. Surgery, or arthroplasty, ♦ Spiral: bone twists, resulting in one or more
to replace damaged joints, such as those in the breaks; common in skiing and skating acci-
hips and knees, is sometimes performed when dents
severe joint damage has occurred. ♦ Depressed: a broken piece of skull bone moves
inward; common with severe head injuries
Bursitis ♦ Colles: breaking and dislocation of the distal

radius that causes a characteristic bulge at the
Bursitis is an inflammation of the bursae, which wrist; caused by falling on an outstretched
are small, fluid-filled sacs surrounding the joints. hand
It frequently affects the shoulders, elbows, hips,
Before a fracture can heal, the bone must be
or knees. Symptoms include severe pain, limited
put back into its proper alignment. This process
movement, and fluid accumulation in the joint.
is called reduction. Closed reduction involves
Treatment consists of administering pain medi-
positioning the bone in correct alignment, usu-
cations, injecting steroids and anesthetics into
ally with traction, and applying a cast or splint to
the affected joint, rest, aspirating (withdrawing
maintain the position until the fracture heals.
fluid with a needle) the joint, and physical ther-
Open reduction involves surgical repair of the
apy to preserve joint motion.
bone. In some cases, special pins, plates, or other
devices are surgically implanted to maintain cor-
rect position of the bone.
Dislocation
A dislocation is when a bone is forcibly displaced
from a joint. It frequently occurs in shoulders,
fingers, knees, and hips. After the dislocation is
reduced (the bone is replaced in the joint), the
dislocation is immobilized with a splint, a cast, or
traction.
Sprain
A sprain is when a twisting action tears the liga-
FIGURE 7-21 Rheumatoid arthritis can cause ments at a joint. The wrists and ankles are com-
permanent deformity and immobility. mon sites for sprains. Symptoms include pain,
162 CHAPTER 7
Transverse
Oblique
(A) Greenstick (B) Closed (C) Open (D) Impacted (E) Comminuted (F) Spiral
(incomplete) (simple, complete) (compound)
(G) Depressed (H) Colles

FIGURE 7-22 Types of fractures.
swelling, discoloration, and limited movement. Osteoporosis

Treatment methods include rest, elevation,
immobilization with an elastic bandage or splint, Osteoporosis, or increased porosity or softening
and/or cold applications. of the bones, is a metabolic disorder caused by a
hormone deficiency (especially estrogen in
women), prolonged lack of calcium in the diet,
and a sedentary lifestyle. The loss of calcium and
Osteomyelitis phosphate from the bones causes the bones to
Osteomyelitis is a bone inflammation usually become porous, brittle, and prone to fracture.
caused by a pathogenic organism. The infectious Bone density tests lead to early detection and
organisms cause the formation of an abscess preventative treatment for osteoporosis. Treat-
within the bone and an accumulation of pus in ment methods include increased intake of cal-
the medullary canal. Symptoms include pain at cium and vitamin D, medications such as
the site, swelling, chills, and fever. Antibiotics are Fosamax and Citracel to increase bone mass,
used to treat the infection. exercise, and/or estrogen replacement.
A. Scoliosis B. Lordosis C. Kyphosis

FIGURE 7-23 Abnormal curvatures of the spinal column.
Ruptured Disk spine to permanently immobilize the affected

vertebrae.
A ruptured disk, also called a herniated or slipped
disk, occurs when an intervertebral disk (pad of
cartilage separating the vertebrae) ruptures or Spinal Curvatures
protrudes out of place and causes pressure on the
spinal nerve. The most common site is at the lum- Abnormal curvatures of the spinal column
bar–sacral area, but a ruptured disk can occur any- include kyphosis, scoliosis, and lordosis (figure
where on the spinal column. Symptoms include 7-23). Kyphosis, or “hunchback,” is a rounded
severe pain, muscle spasm, impaired movement, bowing of the back at the thoracic area. Scoliosis
and/or numbness. Pain, anti-inflammatory, and is a side-to-side, or lateral, curvature of the spine.
muscle relaxant medications may be used as ini- Lordosis, or “swayback,” is an abnormal inward
tial forms of treatment. Other treatments include curvature of the lumbar region. Poor posture,
rest, traction, physical therapy, massage therapy, congenital (at birth) defects, structural defects of
chiropractic treatment, and/or heat or cold the vertebrae, malnutrition, and degeneration of
applications. A laminectomy, surgical removal of the vertebrae can all be causes of these defects.
the protruding disk, may be necessary in severe Therapeutic exercises, firm mattresses, and/or
cases that do not respond to conservative treat- braces are the main forms of treatment. Severe
ment. If pain persists, a spinal fusion may be per- deformities may require surgical repair.
formed to insert a screw/rod assembly into the
STUDENT: Go to the workbook and complete
the assignment sheet for 7:4, Skeletal System.
7:5 Muscular System ♦ List at least three functions of muscles

Objectives ♦ Describe the two main ways muscles attach to
After completing this section, you should be able bones
to: ♦ Demonstrate the five major movements per-
♦ Compare the three main kinds of muscle by formed by muscles
describing the action of each ♦ Describe at least three diseases of the muscu-
♦ Differentiate between voluntary muscle and lar system
involuntary muscle ♦ Define, pronounce, and spell all key terms
164 CHAPTER 7
KEY TERMS
abduction (ab-duck⬘-shun) excitability muscular system
adduction (ad-duck⬘-shun) extensibility origin
cardiac muscle extension rotation
circumduction fascia (fash⬘-ee⬙-ah) skeletal muscle
contract (con-trackt⬘) flexion (flek⬘-shun) tendons
contractibility insertion visceral (smooth) muscle
contracture (con-track⬘-shur) involuntary voluntary
elasticity muscle tone

◆ Athletic Trainer ◆ Myologist ◆ Podiatrist
◆ Chiropractor ◆ Neurologist ◆ Prosthetist
◆ Doctor of Osteopathic ◆ Orthopedist ◆ Rheumatologist
Medicine ◆ Physiatrist ◆ Sports Medicine Physician
◆ Massage Therapist
◆ Physical Therapist
the blood vessels and eyes. Visceral muscle con-

7:5 INFORMATION tracts to cause movement in these organs. Cardiac
More than 600 muscles make up the system muscle and visceral muscle are involuntary,
known as the muscular system. Muscles are meaning they function without conscious thought
bundles of muscle fibers held together by con- or control. Skeletal muscle is attached to bones
nective tissue. All muscles have certain proper- and causes body movement. Skeletal muscle is
ties or characteristics: voluntary because a person has control over its
action. Because cardiac muscle and visceral mus-
♦ Excitability: irritability, the ability to respond cle are discussed in sections on other systems, the
to a stimulus such as a nerve impulse following concentrates on skeletal muscle.
♦ Contractibility: muscle fibers that are stim- Skeletal muscles perform four important
ulated by nerves contract, or become short functions:
and thick, which causes movement
♦ Attach to bones to provide voluntary move-
♦ Extensibility: the ability to be stretched ment
♦ Elasticity: allows the muscle to return to its ♦ Produce heat and energy for the body
original shape after it has contracted or
stretched
♦ Help maintain posture by holding the body
erect
There are three main kinds of muscle: cardiac,
♦ Protect internal organs
visceral, and skeletal (figure 7-24). Cardiac mus-
cle forms the walls of the heart and contracts to Skeletal muscles attach to bones in different
circulate blood. Visceral, or smooth, muscle is ways. Some attach by tendons, which are strong,
found in the internal organs of the body, such as tough, fibrous connective-tissue cords. An exam-
those of the digestive and respiratory systems, and ple is the gastrocnemius muscle on the calf of the
Spindle-shaped cell Nucleus A cell (fiber)

(fiber)
Centrally
located
nucleus
Striations
Cell (fiber) membrane (cross-stripes)
(A) Smooth muscle fibers (nonstriated)
Branching
of cell
Intercalated
disc
(C) Cardiac muscle fibers (striated)
Many nuclei per Striations A cell (fiber)

cell (fiber) (cross-stripes)
(B) Skeletal muscle fibers (striated)
FIGURE 7-24 Three main kinds of muscle.
leg, which attaches to the heelbone by the Achilles ♦ Circumduction: moving in a circle at a joint,
tendon. Other muscles attach by fascia, a tough, or moving one end of a body part in a circle
sheetlike membrane that covers and protects the while the other end remains stationary, such
tissue. Examples include the deep muscles of the as swinging an arm in a circle
trunk and back, which are surrounded by the lum-
bodorsal fascia. When a muscle attaches to a bone, The major superficial muscles of the body are
the end that does not move is called the origin. shown in figure 7-26; the locations and actions of
The end that moves when the muscle contracts is the major muscles are noted in table 7-2.
called the insertion. For example, the origin of Muscles are partially contracted at all times,
the shoulder muscle, called the deltoid, is by the even when not in use. This state of partial con-
clavicle and scapula. Its insertion is on the humerus. traction is called muscle tone and is sometimes
When the deltoid contracts, the area by the scapula described as a state of readiness to act. Loss of
remains stationary, but the area by the humerus muscle tone can occur in severe illness such as
moves and abducts the arm away from the body. paralysis. When muscles are not used for a long
A variety of different actions or movements period, they can atrophy (shrink in size and lose
performed by muscles are shown in figure 7-25 strength). Lack of use can also result in a con-
and are described as follows: tracture, a severe tightening of a flexor muscle
resulting in bending of a joint. Foot drop is a com-
♦ Adduction: moving a body part toward the mon contracture, but the fingers, wrists, knees,
midline and other joints can also be affected.
♦ Abduction: moving a body part away from
the midline
♦ Flexion: decreasing the angle between two
DISEASES AND
bones, or bending a body part ABNORMAL CONDITIONS
♦ Extension: increasing the angle between two
bones, or straightening a body part Fibromyalgia
♦ Rotation: turning a body part around its own Fibromyalgia is chronic, widespread pain in spe-
axis; for example, turning the head from side cific muscle sites. Other symptoms include mus-
to side cle stiffness, numbness or tingling in the arms or
166 CHAPTER 7
Rotation Abduction Adduction
Extension Flexion
FIGURE 7-25 Types of muscle movement.
TABLE 7-2 Locations and Functions of Major Muscles of the Body

MUSCLE LOCATION FUNCTION
Sternocleidomastoid Side of neck Turns and flexes head

Trapezius Upper back and neck Extends head, moves shoulder
Deltoid Shoulder Abducts arm, injection site
Biceps brachii Upper arm Flexes lower arm and supinates hand
Triceps brachii Upper arm Extends and adducts lower arm
Pectoralis major Upper chest Adducts and flexes upper arm
Intercostals Between ribs Moves ribs for breathing
Rectus abdominus Ribs to pubis (pelvis) Compresses abdomen and flexes vertebral column
Latissimus dorsi Spine around to chest Extends and adducts upper arm
Gluteus maximus Buttocks Extends and rotates thigh, injection site
Sartorius Front of thigh Abducts thigh, flexes leg
Quadriceps femoris Front of thigh Extends leg, injection site
Tibialis anterior Front of lower leg Flexes and inverts foot
Gastrocnemius Back of lower leg Flexes and supinates sole of the foot
Masseter
Sternocleidomastoid
Trapezius
Pectoralis
major Deltoid Teres major
Biceps
Infraspinatus
Triceps Triceps
Serratus lateral head
anterior Latissimus
Gluteus dorsi
maximus
External Rectus
oblique abdominis
Biceps
Adductor Rectus Iliotibial femoris
longus femoris band
Sartorius Vastus Semitendinosus

medialis
Vastus
lateralis Tibialis Gastrocnemius
anterior
Gastrocnemius
Soleus
Achilles
tendon
Anterior Surface Muscles Posterior Surface Muscles

FIGURE 7-26 Main muscles of the body.
legs, fatigue, sleep disturbances, headaches, and loses the ability to move. The onset usually occurs
depression. The cause is unknown, but stress, between 2 and 5 years of age. By age 9 to 12, the
weather, and poor physical fitness affect the con- child is confined to a wheelchair. Eventually, the
dition. Treatment is directed toward pain relief muscle weakness affects the heart and dia-
and includes physical therapy, massage, exercise, phragm, resulting in respiratory and/or cardiac
stress reduction, and medication to relax muscles failure that causes death. The life expectancy is
and relieve pain. usually from the late teens to the early twenties.
Although there is no cure, physical therapy is
used to slow the progress of the disease.
Muscular Dystrophy
Muscular dystrophy is actually a group of inher-
ited diseases that lead to chronic, progressive
Myasthenia Gravis
muscle atrophy. Muscular dystrophy usually Myasthenia gravis is a chronic condition where
appears in early childhood; most types result in nerve impulses are not properly transmitted to
total disability and early death. The most com- the muscles. This leads to progressive muscular
mon type is Duchenne muscular dystrophy, weakness and paralysis. If the condition affects
which is caused by a genetic defect. At birth, the the respiratory muscles, it can be fatal. Although
infant is healthy. As muscle cells die, the child the cause is unknown, myasthenia gravis is
168 CHAPTER 7
thought to be an autoimmune disease, with anti- Strain

bodies attacking the body’s own tissues. There is
no cure, and treatment is supportive. A strain is an overstretching of or injury to a mus-
cle and/or tendon. Frequent sites include the back,
arms, and legs. Prolonged or sudden muscle exer-
tion is usually the cause. Symptoms include myal-
Muscle Spasms gia (muscle pain), swelling, and limited movement.
Muscle spasms, or cramps, are sudden, painful, Treatment methods include rest, muscle relaxants
involuntary muscle contractions. They usually or pain medications, elevating the extremity, and
occur in the legs or feet and may result from over- alternating hot and cold applications.
exertion, low electrolyte levels, or poor circula-
tion. Gentle pressure and stretching of the muscle STUDENT: Go to the workbook and complete
are used to relieve the spasm. the assignment sheet for 7:5, Muscular System.
7:6 Nervous System ♦ Explain three functions of the spinal cord

Objectives ♦ Name the three meninges
After completing this section, you should be able ♦ Describe the circulation and function of cere-
to: brospinal fluid
♦ Identify the four main parts of a neuron ♦ Contrast the actions of the sympathetic and
♦ Name the two main divisions of the nervous parasympathetic nervous systems
system ♦ Describe at least five diseases of the nervous
♦ Describe the function of each of the five main system
parts of the brain ♦ Define, pronounce, and spell all key terms
KEY TERMS
autonomic nervous system hypothalamus parasympathetic (par⬙-ah-
brain medulla oblongata (meh- sim⬙-pah-thet⬘-ik)
central nervous system due⬘-la ob-lawn-got⬘-ah) peripheral nervous system
(CNS) meninges (singular: meninx) (PNS) (peh-rif⬘-eh-ral)
cerebellum (seh⬙-reh-bell⬘- (meh-nin⬘-jeez) pons (ponz)
um) midbrain somatic nervous system
cerebrospinal fluid (seh-ree⬙- nerves spinal cord
broh-spy⬘-nal fluid) nervous system sympathetic
cerebrum (seh-ree⬘-brum) neuron (nur⬘-on) thalamus
diencephalon ventricles

◆ Acupressurist ◆ Electroencephalographic ◆ Neurosurgeon
◆ Acupuncturist
Technologist ◆ Physical Therapist
◆ Electroneurodiagnostic
◆ Anesthesiologist ◆ Polysomnographic
Technologist Technologist
◆ Chiropractor
◆ Mental Health Technician
◆ Psychiatrist
◆ Diagnostic Imager
◆ Neurologist
◆ Psychologist
◆ Doctor of Osteopathic
Medicine
7:6 INFORMATION Impulses coming from one axon “jump” the syn-
apse to get to the dendrite of another neuron,
The nervous system is a complex, highly orga- which will carry the impulse in the right direc-
nized system that coordinates all the activities of tion. Special chemicals, called neurotransmitters,
the body. This system enables the body to respond located at the end of each axon, allow the nerve
and adapt to changes that occur both inside and impulses to pass from one neuron to another. In
outside the body. this way, impulses can follow many different
The basic structural unit of the nervous sys- routes.
tem is the neuron, or nerve cell (figure 7-27). It Nerves are a combination of many nerve
consists of a cell body containing a nucleus; nerve fibers located outside the brain and spinal cord.
fibers, called dendrites (which carry impulses Afferent, or sensory, nerves carry messages from
toward the cell body); and a single nerve fiber, all parts of the body to the brain and spinal cord.
called an axon (which carries impulses away from Efferent, or motor, nerves carry messages from
the cell body). Many axons have a lipid (fat) cov- the brain and spinal cord to the muscles and
ering called a myelin sheath, which increases the glands. Associative, or internuncial, nerves carry
rate of impulse transmission and insulates and both sensory and motor messages.
maintains the axon. The axon of one neuron lies There are two main divisions to the nervous
close to the dendrites of many other neurons. The system: the central nervous system and the
spaces between them are known as synapses. peripheral nervous system (figure 7-28). The
Dendrites
Nucleus
Axon
Terminal
branches
}
Myelin sheath
Axon
Cell body Myelin
Nodes of Ranvier
Schwann cells
FIGURE 7-27 A neuron, the basic structural unit of the nervous system.
170 CHAPTER 7
Nervous system
CNS PNS
Brain 12 cranial nerve pairs
Spinal cord 31 spinal nerve pairs
Somatic division Autonomic division
Sympathetic Parasympathetic
Sensory neurons Motor neurons

Motor neurons Sensory neurons
Sensory information Motor impulses from
Motor impulses Sensory information
from skin, skeletal CNS to smooth
from CNS to skeletal from visceral organs
muscles and joints muscles, cardiac
muscles to CNS
to CNS muscle and glands
FIGURE 7-28 Divisions of the nervous system.
central nervous system (CNS) consists of the brum is responsible for reasoning, thought,
brain and spinal cord. The peripheral nervous memory, judgment, speech, sensation, sight,
system (PNS) consists of the nerves and has two smell, hearing, and voluntary body move-
divisions: the somatic nervous system and the ment.
autonomic nervous system. The somatic ner- ♦ Cerebellum: the section below the back of
vous system carries messages between the CNS the cerebrum. It is responsible for muscle
and the body. The autonomic nervous system coordination, balance, posture, and muscle
contains the sympathetic and parasympathetic tone.
nervous systems, which work together to control
involuntary body functions. ♦ Diencephalon: the section located between
the cerebrum and midbrain. It contains two
structures: the thalamus and hypothalamus.
CENTRAL NERVOUS The thalamus acts as a relay center and
directs sensory impulses to the cerebrum. It
SYSTEM also allows conscious recognition of pain and
temperature. The hypothalamus regulates
The brain is a mass of nerve tissue well protected and controls the autonomic nervous system,
by membranes and the cranium, or skull (figure temperature, appetite, water balance, sleep,
7-29). The main sections include: and blood vessel constriction and dilation.
♦ Cerebrum: the largest and highest section of The hypothalamus is also involved in emo-
the brain. The outer part is arranged in folds, tions such as anger, fear, pleasure, pain, and
called convolutions, and separated into lobes. affection.
The lobes include the frontal, parietal, tempo- ♦ Midbrain: the section located below the
ral, and occipital, named from the skull bones cerebrum at the top of the brainstem. It is
that surround them (figure 7-30). The cere- responsible for conducting impulses between
Lateral ventricle
Interventricular foramen Convolutions
Sulci
Skull
Dura mater
Arachnoid Meninges
Cerebrum
Pia mater
Corpus callosum
Third ventricle
Cerebral aqueduct
Thalamus
Diencephalon Hypothalamus Fourth ventricle
Pituitary gland
Midbrain
Brain stem Pons Cerebellum
Medulla oblongata
Spinal cord
FIGURE 7-29 The brain and spinal cord.
brain parts and for certain eye and auditory dura mater is the thick, tough, outer layer. The
reflexes. middle layer is delicate and weblike, and is called
♦ Pons: the section located below the midbrain the arachnoid membrane. It is loosely attached to
and in the brainstem. It is responsible for con- the other meninges to allow space for fluid to
ducting messages to other parts of the brain; flow between the layers. The innermost layer, the
for certain reflex actions including chewing, pia mater, is closely attached to the brain and spi-
tasting, and saliva production; and for assist- nal cord, and contains blood vessels that nourish
ing with respiration. the nerve tissue.
The brain has four ventricles, hollow spaces
♦ Medulla oblongata: the lowest part of the that connect with each other and with the space
brainstem. It connects with the spinal cord under the arachnoid membrane (the subarach-
and is responsible for regulating heartbeat, noid space). The ventricles are filled with a clear,
respiration, swallowing, coughing, and blood colorless fluid called cerebrospinal fluid. This
pressure. fluid circulates continually between the ventri-
The spinal cord continues down from cles and through the subarachnoid space. It
the medulla oblongata and ends at the first or serves as a shock absorber to protect the brain
second lumbar vertebrae (figure 7-31). It is sur- and spinal cord. It also carries nutrients to some
rounded and protected by the vertebrae. The spi- parts of the brain and spinal cord and helps
nal cord is responsible for many reflex actions remove metabolic products and wastes. The fluid
and for carrying sensory (afferent) messages up is produced in the ventricles of the brain by the
to the brain and motor (efferent) messages from special structures called choroid plexuses. After
the brain to the nerves that go to the muscles and circulating, it is absorbed into the blood vessels
glands. of the dura mater and returned to the blood-
The meninges are three membranes that stream through special structures called arach-
cover and protect the brain and spinal cord. The noid villi.
172 CHAPTER 7
Sulci
Convolutions of
cerebral hemisphere Parietal lobe
(gyri)
Cerebrum
Frontal lobe
Occipital lobe
Temporal lobe
(A) Midbrain
Brainstem Pons Cerebellum

Medulla
Lateral View
h Sensory
ec
Motor
Spe
Emotions Pain
Personality Heat
Morality Touch
Intellect
Speech
Hearing
Vision
(B)
Smelling
Muscle tone
Relays impulses Equilibrium
Autonomic nervous control Walking
Controls blood pressure Eye reflexes Dancing
Maintains body temperature Conducts impulses Heart
Stimulates antidiuretic hormone Lungs
Assists with appetite regulation Breathing
Stomach
Acts on intestines Chewing
Blood vessels
Role in emotions Taste
Helps maintain wakefulness
FIGURE 7-30 Each lobe of the brain is responsible for different functions.
PERIPHERAL NERVOUS
SYSTEM cranial nerves are responsible for special senses
such as sight, hearing, taste, and smell. Others
The peripheral nervous system consists of the receive general sensations such as touch, pres-
somatic and the autonomic nervous systems. sure, pain, and temperature, and send out
impulses for involuntary and voluntary muscle
control. The spinal nerves carry messages to and
Somatic Nervous System from the spinal cord and are mixed nerves, both
The somatic nervous system consists of 12 pairs sensory (afferent) and motor (efferent). There are
of cranial nerves and their branches, and 31 pairs 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1
of spinal nerves and their branches. Some of the pair of coccygeal spinal nerves. Each nerve goes
DISEASES AND
ABNORMAL
Cervical plexus
C1–C5
CONDITIONSS
Brachial plexus
C5–T1 Amyotrophic Lateral
Sclerosis
Amyotrophic lateral sclerosis (ALS), also known
as Lou Gehrig’s disease, is a chronic, degenerative
neuromuscular disease. The cause is unknown,
but genetic or viral-immune factors are sus-
Lumbar plexus
L1–L4
pected. Nerve cells in the CNS that control vol-
Femoral nerve
untary movement degenerate, resulting in a
weakening and atrophy (wasting away) of the
Sacral plexus
L4–S3
muscles they control. Initial symptoms include
Sciatic nerve muscle weakness, abnormal reflexes, tripping
and falling, impaired hand and arm movement,
and difficulty in speaking or swallowing. As the
disease progresses, more muscles are affected,
FIGURE 7-31 The spinal cord and nerves. resulting in total body paralysis. In the later
stages, the patient loses all ability to communi-
cate, breathe, eat, and move. Mental acuity is
unaffected, so an active mind is trapped inside a
directly to a particular part of the body or net- paralyzed body. No treatment exists, but drugs
works with other spinal nerves to form a plexus such as Riluzole may slow the progress of the dis-
that supplies sensation to a larger segment of the ease. ALS is usually fatal within 4 to 6 years of
body. symptom onset, but some patients with slower
rates of progression have survived 10–20 years
Autonomic Nervous System after the onset of the disease.
The autonomic nervous system is an important

part of the peripheral nervous system. It helps
maintain a balance in the involuntary functions
Carpal Tunnel Syndrome
of the body and allows the body to react in times Carpal tunnel syndrome is a condition that occurs
of emergency. There are two divisions to the auto- when the medial nerve and tendons that pass
nomic nervous system: the sympathetic and through a canal or “tunnel” on their way from the
parasympathetic nervous systems. These two forearm to the hands and fingers are pinched.
systems usually work together to maintain a bal- Repetitive movement of the wrist causes swelling
anced state, or homeostasis, in the body and to around this tunnel, which puts pressure on the
control involuntary body functions at proper nerves and tendons. Symptoms include pain,
rates. In times of emergency, the sympathetic muscle weakness in the hand, and impaired
nervous system prepares the body to act by movement. A classic symptom is pain, numb-
increasing heart rate, respiration, and blood pres- ness, and tingling in the thumb, ring finger,
sure, and slowing activity in the digestive tract. and middle finger. Initially, carpal tunnel is
This is known as the fight or flight response. After treated with anti-inflammatory medications,
the emergency, the parasympathetic nervous analgesics for pain, and splinting to immobilize
system counteracts the actions of the sympa- the joint. Severe cases that do not respond to this
thetic system by slowing heart rate, decreasing treatment may require surgery to enlarge the
respiration, lowering blood pressure, and increas- “tunnel” and relieve the pressure on the nerves
ing activity in the digestive tract. and tendons.
174 CHAPTER 7
Cerebral Palsy person recover from or adapt to the symptoms

that are present. Physical, occupational, and
Cerebral palsy is a disturbance in voluntary mus- speech therapy are the main forms of treatment.
cle action and is caused by brain damage. Lack of
oxygen to the brain, birth injuries, prenatal
rubella (German measles), and infections can all Encephalitis
cause cerebral palsy. Of the three forms—spastic,
athetoid, and atactic—spastic is the most com- Encephalitis is an inflammation of the brain and
mon. Symptoms include exaggerated reflexes, is caused by a virus, bacterium, chemical agent,
tense muscles, contracture development, sei- or as a complication of measles, chicken pox, or
zures, speech impairment, spasms, tremors, and mumps. The virus is frequently contracted from a
in some cases, mental retardation. Although there mosquito bite because mosquitos can carry the
is no cure, physical, occupational, and speech encephalitis virus. Symptoms vary but may
therapy are important aspects of treatment. Mus- include fever, extreme weakness or lethargy, visual
cle relaxants, anticonvulsive drugs, casts, braces, disturbances, headaches, vomiting, stiff neck and
and/or orthopedic surgery (for severe contrac- back, disorientation, seizures, and coma. Treat-
tures) are also used. ment methods are supportive and include antivi-
ral drugs, maintenance of fluid and electrolyte
balance, antiseizure medication, and monitoring
Cerebrovascular Accident of respiratory and kidney function.
A cerebrovascular accident (CVA), also called a
brain attack, stroke, or apoplexy, occurs when the Epilepsy
blood flow to the brain is impaired, resulting in a
lack of oxygen and a destruction of brain tissue. It Epilepsy, or seizure syndrome, is a brain disorder
can be caused by cerebral hemorrhage resulting associated with abnormal electrical impulses in
from hypertension, an aneurysm, or a weak blood the neurons of the brain. Although causes can
vessel; or by an occlusion, or blockage, caused by include brain injury, birth trauma, tumors, toxins
atherosclerosis or a thrombus (blood clot). Fac- such as lead or carbon monoxide, and infections,
tors that increase the risk for a CVA include smok- many cases of epilepsy are idiopathic (spontane-
ing, a high-fat diet, obesity, and a sedentary ous, or primary). Absence, or petit mal, seizures
lifestyle. Symptoms vary depending on the area are milder and are characterized by a loss of con-
and amount of brain tissue damaged. Some com- sciousness lasting several seconds. They are com-
mon symptoms of an acute CVA include loss of mon in children and frequently disappear by late
consciousness, weakness or paralysis on one side adolescence. Generalized tonic-clonic, or grand
of the body (hemiplegia), dizziness, dysphagia mal, are the most severe seizures. They are char-
(difficult swallowing), visual disturbances, men- acterized by a loss of consciousness lasting sev-
tal confusion, aphasia (speech and language eral minutes; convulsions accompanied by violent
impairment), and incontinence. When a CVA shaking and thrashing movements; hypersaliva-
occurs, immediate care during the first 3 hours tion, causing foaming at the mouth; and loss of
can help prevent brain damage. Treatment with body functions. Some individuals experience an
thrombolytic or “clot-busting” drugs such as TPA aura, such as a particular smell, ringing in the
(tissue plasminogen activator) or angioplasty of ears, visual disturbances, or tingling in the fingers
the cerebral arteries can dissolve a blood clot and and/or toes just before a seizure occurs. Anticon-
restore blood flow to the brain. Computerized vulsant drugs are effective in controlling epilepsy.
tomography (CT) scans (noninvasive computer-
ized X-rays that show cross-sectional views of
body tissue) are used to determine the cause of
Hydrocephalus
the CVA. Clot-busting drugs cannot be used if the Hydrocephalus is an excessive accumulation of
CVA is caused by a hemorrhage. Neuroprotective cerebrospinal fluid in the ventricles and, in some
agents, or drugs that help prevent injury to neu- cases, the subarachnoid space of the brain. It is
rons, are also used initially to prevent permanent usually caused by a congenital (at birth) defect,
brain damage. Additional treatment depends on infection, or tumor that obstructs the flow of
symptoms and is directed toward helping the cerebrospinal fluid out of the brain. Symptoms
include an abnormally enlarged head, prominent numbness. As the disease progresses, tremors,
forehead, bulging eyes, irritability, distended muscle spasticity, paralysis, speech impairment,
scalp veins, and when pressure prevents proper emotional swings, and incontinence occur. There
development of the brain, retardation. The con- is no cure. Treatment methods such as physical
dition is treated by the surgical implantation of a therapy, muscle relaxants, steroids, and psycho-
shunt (tube) between the ventricles and the veins, logical counseling are used to maintain functional
heart, or abdominal peritoneal cavity to provide ability as long as possible.
for drainage of the excess fluid.
Neuralgia
Meningitis Neuralgia is nerve pain. It is caused by inflamma-
Meningitis is an inflammation of the meninges of tion, pressure, toxins, and other disease. Treat-
the brain and/or spinal cord and is caused by a ment is directed toward eliminating the cause of
bacterium, virus, fungus, or toxin such as lead or the pain.
arsenic. Symptoms include high fever, headaches,
back and neck pain and stiffness, nausea and vom-
iting, delirium, convulsions, and if untreated, coma Paralysis
and death. Treatment methods include antibiotics, Paralysis usually results from a brain or spinal
antipyretics (for fever), anticonvulsants, and/or cord injury that destroys neurons and results in a
medications for pain and cerebral edema. loss of function and sensation below the level of
injury. Hemiplegia is paralysis on one side of the
body and is caused by a tumor, injury, or CVA.
Multiple Sclerosis Paraplegia is paralysis in the lower extremities or
Multiple sclerosis (MS) is a chronic, progressive, lower part of the body and is caused by a spinal
disabling condition resulting from a degeneration cord injury. Quadriplegia is paralysis of the arms,
of the myelin sheath in the CNS. It usually occurs legs, and body below the spinal cord injury. Cur-
between the ages of 20 and 40 (figure 7-32). The rently, no cure exists, although much research is
cause is unknown but genetics or a viral infection being directed toward repairing spinal cord dam-
of the immune system are suspected. The disease age. Treatment methods are supportive and
progresses at different rates and has periods of include physical and occupational therapy.
remission. Early symptoms include visual distur-
bances such as diplopia (double vision), weak-
ness, fatigue, poor coordination, and tingling and Parkinson’s Disease
Parkinson’s disease is a chronic, progressive con-
dition involving degeneration of brain cells, usu-
ally in persons over 50 years of age. Symptoms
include tremors, stiffness, muscular rigidity, a for-
ward leaning position, a shuffling gait, difficulty in
stopping while walking, loss of facial expression,
drooling, mood swings and frequent depression,
and behavioral changes. Although no cure exists, a
drug called levodopa is used to relieve the symp-
toms. In some cases, surgery can be performed to
destroy selectively a small area of the brain and
control involuntary movements. Physical therapy
is also used to limit muscular rigidity.
Shingles
Shingles, or herpes zoster, is an acute inflamma-
FIGURE 7-32 Multiple sclerosis usually occurs tion of nerve cells and is caused by the herpes
between the ages of 20 and 40. virus, which also causes chicken pox. It charac-
176 CHAPTER 7
teristically occurs in the thoracic area on one side ness, itching, fever, and abnormal skin sensa-
of the body and follows the path of the affected tions. Treatment is directed toward relieving pain
nerves (figure 7-33). Fluid-filled vesicles appear and itching until the inflammation subsides, usu-
on the skin, accompanied by severe pain, red- ally in 1–4 weeks.

the assignment sheet for 7:6, Nervous System.
7:7 Special Senses

Objectives
to:
♦ Identify five special senses
♦ Label the major parts on a diagram of the eye
♦ Trace the pathway of light rays as they pass
through the eye
♦ Label the major parts on a diagram of the ear
♦ Trace the pathway of sound waves as they
pass through the ear
♦ Explain how the ear helps maintain balance
and equilibrium
♦ State the locations of the four main taste
receptors
♦ List at least four general senses located
throughout the body
♦ Describe at least six diseases of the eye and
FIGURE 7-33 The vesicles of shingles follow the ear
path of the affected nerves. ♦ Define, pronounce, and spell all key terms
KEY TERMS
aqueous humor iris retina (ret⬘-in-ah)
(a⬘-kwee⬙-us hue-more) lacrimal glands sclera (sklee⬘-rah)
auditory canal (lack⬘-rih⬙-mal) semicircular canals
auricle (or⬘-eh-kul⬙) lens tympanic membrane
choroid coat (koh⬘-royd) organ of Corti (tim-pan⬘-ik)
cochlea (co⬘-klee-ah) ossicles (os⬘-ick-uls) vestibule (ves⬘-tih-bewl)
conjunctiva pinna (pin⬘-nah) vitreous humor
(kon-junk⬙-tye⬘-vah) pupil (vit⬘-ree-us hue⬘-more)
cornea refracts
eustachian tube
(you-stay⬘-she-en)

◆ Allergist ◆ Ophthalmic Laboratory ◆ Ophthalmologist
◆ Audiologist
Technician ◆ Optician
◆ Ophthalmic Medical
◆ Eye, Ear, Nose, and Throat ◆ Optometrist
Specialist Technologist
◆ Otolaryngologist
◆ Ophthalmic Technician
◆ Ophthalmic Assistant
◆ Otologist
The eye (figure 7-34A) is well protected. It is

7:7 INFORMATION partially enclosed in a bony socket of the skull.
Special senses allow the human body to react to Eyelids and eyelashes help keep out dirt and
the environment by providing for sight, hearing, pathogens. Lacrimal glands in the eye produce
taste, smell, and balance maintenance. These tears, which constantly moisten and cleanse the
senses are possible because the body has struc- eye. The tears flow across the eye and drain
tures that receive sensations, nerves that carry through the nasolacrimal duct into the nasal cav-
sensory messages to the brain, and a brain that ity. A mucous membrane, called the conjunc-
interprets and responds to sensory messages. tiva, lines the eyelids and covers the front of the
eye to provide additional protection and lubrica-
tion.
THE EYE There are three main layers to the eye (figure
7-34B). The outermost layer is the tough connec-
The eye is the organ that controls the special tive tissue called the sclera. It is frequently
sense of sight. It receives light rays and transmits referred to as the “white” of the eye. The sclera
impulses from the rays to the optic nerve, which maintains the shape of the eye. Extrinsic muscles,
carries the impulses to the brain, where they are responsible for moving the eye within the socket,
interpreted as vision, or sight. are attached to the outside of the sclera. The cor-
Ciliary body and
muscle
Suspensory
ligament
Conjunctiva
Iris
Eyebrow Retina
Lacrimal gland
(under eyelid) Pupil Pupil Retinal arteries
Sclera and veins
(white of eye) Path of light Fovea
Iris centralis
Anterior chamber
(aqueous humor)
Cornea Optic
Nasolacrimal nerve
duct Choroid coat
into nose Lens
Sclera
Suspensory
ligament
Posterior chamber
(A) (vitreous humor) (B)
FIGURE 7-34 (A) External view of the eye; (B) structures of the eye.
178 CHAPTER 7
nea is a circular, transparent part of the front of When light rays enter the eye, they pass
the sclera. It allows light rays to enter the eye. The through a series of parts that refract the rays so
middle layer of the eye, the choroid coat, is that the rays focus on the retina. These parts are
interlaced with many blood vessels that nourish the cornea, the aqueous humor, the pupil, the lens,
the eyes. The innermost layer of the eye is the and the vitreous humor. In the retina, the light rays
retina. It is made of many layers of nerve cells, (image) are picked up by the rods and cones,
which transmit the light impulses to the optic changed into nerve impulses, and transmitted by
nerve. Two such special cells are cones and rods. the optic nerve to the occipital lobe of the cere-
Cones are sensitive to color and are used mainly brum, where sight is interpreted. If the rays are not
for vision when it is light. Most of the cones are refracted correctly by the various parts, vision can
located in a depression located on the back sur- be distorted or blurred (figure 7-35).
face of the retina called the fovea centralis; this is
the area of sharpest vision. Rods are used for
vision when it is dark or dim. Diseases and Abnormal
The iris is the colored portion of the eye. It is
located behind the cornea on the front of the
Conditions
choroid coat. The opening in the center of the iris Amblyopia
is called the pupil. The iris contains two muscles, Amblyopia, or lazy eye, commonly occurs in early
which control the size of the pupil and regulate childhood. It results in poor vision in one eye and
the amount of light entering the eye. is caused by the dominance of the other eye.
Other special structures are also located in Treatment methods include covering the good
the eye. The lens is a circular structure located eye to stimulate development of the “lazy” eye,
behind the pupil and suspended in position by exercises to strengthen the weak eye, corrective
ligaments. It refracts (bends) light rays so the lenses, and/or surgery. If the condition is not
rays focus on the retina. The aqueous humor is treated before 8 to 9 years of age, blindness of the
a clear, watery fluid that fills the space between affected eye may occur.
the cornea and iris. It helps maintain the forward
curvature of the eyeball and refracts light rays. Astigmatism
The vitreous humor is the jellylike substance Astigmatism is an abnormal shape or curvature
that fills the area behind the lens. It helps main- of the cornea that causes blurred vision. Light
tain the shape of the eyeball and also refracts light rays focus on multiple areas of the retina (figure
rays. A series of muscles located in the eye pro- 7-35). Corrective lenses (glasses or contact lenses)
vide for eye movement. correct the condition.
(A) Normal eye (B) Myopia (nearsightedness) (C) Hyperopia (farsightedness)

Light rays focus on the retina Light rays focus in front Light rays focus beyond
of the retina the retina
(D) Presbyopia (E) Astigmatism

Light rays focus Light rays focus on multiple
behind the retina areas of the retina
FIGURE 7-35 Improper refraction of light rays causes impaired vision.
Cataract the image focuses behind the retina (figure 7-35).

A cataract occurs when the normally clear lens Vision is corrected by the use of convex lenses.
becomes cloudy or opaque (figure 7-36). This
occurs gradually, usually as a result of aging, but Macular Degeneration
may be the result of trauma. Symptoms include Macular degeneration, a major cause of vision loss
blurred vision, halos around lights, gradual vision and blindness, is a disease of the macula, the cen-
loss, and in later stages, a milky white pupil. Sight tral and most sensitive section of the retina. It is an
is restored by the surgical removal of the lens. An age-related disorder caused by damage to the
implanted intraocular lens or prescription glasses blood vessels that nourish the retina. The most
or contact lenses correct the vision and compen- common type is dry macular degeneration that
sate for the removed lens. occurs as fatty deposits decrease the blood supply
to the retina, resulting in a gradual thinning of the
Conjunctivitis retina. It progresses slowly and results in blurred
Conjunctivitis, or pink eye, is a contagious inflam- distorted vision with an absence of central vision.
mation of the conjunctiva and is usually caused Peripheral (side) vision is usually not affected. No
by a bacterium or virus. Symptoms include red- treatment currently exists, but optical aids such as
ness, swelling, pain, and, at times, pus formation special lighting or magnifiers may improve vision
in the eye. Antibiotics, frequently in the form of slightly. Wet macular degeneration is caused by an
an eye ointment, are used to treat conjunctivitis. abnormal growth of blood vessels that leak blood
and fluids that damage the retina. Laser treatment
Glaucoma to coagulate or seal the leaking blood vessels can
Glaucoma is a condition of increased intraocular preserve sight. New research directed toward cre-
(within the eye) pressure caused by an excess ation of an artificial retina or bionic eye may allow
amount of aqueous humor. It is common after individuals with this disease to regain the ability to
age 40 and is a leading cause of blindness. A see light and large objects in the future.
tonometer (instrument that measures intraocu-
lar pressure) is usually used during regular eye Myopia
examinations to check for this condition. Symp- Myopia is nearsightedness. It occurs when the
toms include loss of peripheral (side) vision, light rays are refracted too sharply and the image
halos around lights, limited night vision, and focuses in front of the retina (figure 7-35). Vision is
mild aching. Glaucoma is usually controlled with corrected by the use of concave lenses. A newer
medications that decrease the amount of fluid method of treatment is a surgical procedure called
produced or improve the drainage. In some cases, radial keratotomy (RK). Small incisions are made
surgery is performed to create an opening for the in the cornea to flatten it so it can refract light rays
flow of the aqueous humor. correctly. In some cases, a laser is used to flatten
the cornea without cutting. RK can correct myopia
Hyperopia and eliminate the need for corrective lenses.
Hyperopia is farsightedness. It occurs when the
light rays are not refracted sharply enough and Presbyopia
Presbyopia is farsightedness caused by a loss of
lens elasticity. Light rays focus behind the retina
(figure 7-35). It results from the normal aging
process and is treated by the use of corrective
lenses or “reading” glasses.
Strabismus
Strabismus is a disorder in which the eyes do not
move or focus together. The eyes may move
inward (cross-eyed) or outward, or up or down. It
is caused by muscle weakness in one or both eyes.
FIGURE 7-36 A cataract occurs when the lens of Treatment methods include eye exercises, cover-
the eye becomes cloudy or opaque. (Courtesy of ing the good eye, corrective lenses, and/or sur-
National Eye Institute, NEH) gery on the muscles that move the eye.
180 CHAPTER 7
The inner ear is the most complex portion of

THE EAR the ear. It is separated from the middle ear by a
membrane called the oval window. The first sec-
The ear is the organ that controls the special
tion is the vestibule, which acts as the entrance
senses of hearing and balance. It transmits
to the two other parts of the inner ear. The
impulses from sound waves to the auditory nerve
cochlea, shaped like a snail’s shell, contains del-
(vestibulocochlear), which carries the impulses
icate, hairlike cells, which compose the organ of
to the brain for interpretation as hearing. The ear
Corti, a receptor of sound waves. The organ of
is divided into three main sections: the outer ear,
Corti transmits the impulses from sound waves
the middle ear, and the inner ear (figure 7-37).
to the auditory nerve. This nerve carries the
The outer ear contains the visible part of
impulses to the temporal lobe of the cerebrum,
the ear, called the pinna, or auricle. The pinna
where they are interpreted as hearing. Semicir-
is elastic cartilage covered by skin. It leads to
cular canals are also located in the inner ear.
a canal, or tube, called the external auditory
These canals contain a liquid and delicate, hair-
meatus, or auditory canal. Special glands in
like cells that bend when the liquid moves with
this canal produce cerumen, a wax that protects
head and body movements. Impulses sent from
the ear. Sound waves travel through the auditory
the semicircular canals to the cerebellum of the
canal until they reach the eardrum, or tympanic
brain help to maintain our sense of balance and
membrane. The tympanic membrane separates
equilibrium.
the outer ear from the middle ear. It vibrates when
sound waves hit it and transmits the sound waves
to the middle ear.
The middle ear is a small space, or cavity, in Diseases and Abnormal
the temporal bone. It contains three small bones
(ossicles): the malleus, the incus, and the sta-
Conditions
pes. The bones are connected and transmit sound Hearing Loss
waves from the tympanic membrane to the inner Hearing loss is classified as either conductive or
ear. The middle ear is connected to the pharynx, sensory. Conductive hearing loss or deafness
or throat, by a tube called the eustachian tube. occurs when sound waves are not conducted
This tube allows air to enter the middle ear and to the inner ear. Possible causes include a wax
helps equalize air pressure on both sides of the (cerumen) plug, a foreign body obstruction, oto-
tympanic membrane. sclerosis, an infection, or a ruptured tympanic
Incus
Malleus Semicircular
canals
Branches of
vestibulocochlear
Auricle nerve
Cochlea
External Oval window

auditory canal
Round window
Auditory
(eustachian) tube
Tympanic membrane Stapes and footplate

FIGURE 7-37 Structures of the ear.
membrane. Treatment is directed toward eliminat- Symptoms include gradual hearing loss, tinnitus,
ing the cause. Surgery and the use of hearing aids and at times, vertigo. Surgical removal of the sta-
are common forms of treatment. Sensory hearing pes and insertion of an artificial stapes corrects
loss or deafness occurs when there is damage to the condition.
the inner ear or auditory nerve. This type of hear-
ing loss usually cannot be corrected, but cochlear
implants can improve severe hearing loss.
THE TONGUE AND
Ménière’s Disease SENSE OF TASTE
Ménière’s disease results from a collection of fluid
in the labyrinth of the inner ear and a degeneration The tongue is a mass of muscle tissue with pro-
of the hair cells in the cochlea and vestibule. Symp- jections called papillae (figure 7-38). The papillae
toms include severe vertigo (dizziness), tinnitus contain taste buds that are stimulated by the fla-
(ringing in the ears), nausea and vomiting, loss of vors of foods moistened by saliva. There are four
balance, and a tendency to fall. Forms of treatment main tastes: sweet tastes and salty tastes at the
include drugs to reduce the fluid, draining the fluid, tip of the tongue; sour tastes at the sides of the
and antihistamines. In severe, chronic cases, sur- tongue; and bitter tastes at the back of the tongue.
gery to destroy the cochlea may be performed; Taste is influenced by the sense of smell.
however, this causes permanent deafness.
Otitis Externa
Otitis externa is an inflammation of the external
THE NOSE AND SENSE
auditory canal. It is caused by a pathogenic organ- OF SMELL
ism such as a bacterium or virus. Swimmer’s ear
is one form. It is caused by swimming in contam- The nose is the organ of smell (figure 7-39). The
inated water. Inserting bobby pins, fingernails, or sense of smell is made possible by olfactory
cotton swabs into the ear can also cause this con- receptors, which are located in the upper part of
dition. Treatment methods include antibiotics; the nasal cavity. Impulses from these receptors
warm, moist compresses; and/or pain medica- are carried to the brain by the olfactory nerve.
tions. The human nose can detect more than 6,000 dif-
ferent smells. The sense of smell is more sensitive
Otitis Media than taste, but is closely related to the sense of
Otitis media is an inflammation or infection of the taste. This is clearly illustrated by the fact that
middle ear that is caused by a bacterium or virus. It food does not taste as good when you have a head
frequently follows a sore throat because organisms cold and your sense of smell is impaired.
from the throat can enter the middle ear through
the eustachian tube. Infants and young children
are very susceptible to otitis media because the THE SKIN AND
eustachian tube is angled differently than in adults.
Secretions from the nose and throat accumulate GENERAL SENSES
in the middle ear, resulting in an inflammatory
General sense receptors for pressure, heat, cold,
response that causes the eustachian tube to swell
touch, and pain are located throughout the body
shut. Symptoms include severe pain, fever, vertigo
in the skin and connective tissue. Each receptor
(dizziness), nausea and vomiting, and fluid buildup
perceives only one type of sense. For example,
in the middle ear. Treatment usually consists of
the skin contains special receptors for heat and
administering antibiotics and pain medications. At
different receptors for cold. Messages from these
times, a myringotomy (incision of the tympanic
receptors allow the human body to respond to its
membrane) is performed, and tubes are inserted
environment and help it react to conditions that
to relieve pressure and allow fluid to drain.
can cause injury.
Otosclerosis
Otosclerosis occurs when the stapes becomes STUDENT: Go to the workbook and complete
immobile, causing conductive hearing loss. the assignment sheet for 7:7, Special Senses.
182 CHAPTER 7
Quinine Circumvallate
papillae
Gustatory
Bitter (taste)
pores
Duct of
gland
Sour
Nerve
endings
Salt Sweet Schematic drawing of

section of tastebuds from
circumvallate papillae
FIGURE 7-38 Locations of taste buds.
Olfactory Olfactory Bulb of

cells nerve olfactory
nerve Olfactory
Glands center in
brain
Section of
olfactory
mucosa
FIGURE 7-39 The sense of smell.

♦ List the three major types of blood vessels and

7:8 Circulatory System the action of each type
Objectives ♦ Compare the three main types of blood cells
by describing the function of each
to: ♦ Describe at least five diseases of the circula-
tory system
♦ Label the layers, chambers, valves, and major
blood vessels on a diagram of the heart ♦ Define, pronounce, and spell all key terms
♦ Differentiate between systole and diastole by
explaining what happens in the heart during
each phase
KEY TERMS
aortic valve (ay-or⬘-tick) hemoglobin (hee⬘-mow- pulmonary valve
arrhythmias glow⬙-bin) right atrium
arteries left atrium (ay⬘-tree-um) right ventricle
blood left ventricle (ven⬘tri⬙-kul) septum
capillaries (cap⬘-ih-lair-eez) leukocytes (lew⬘-coh-sitez⬙) systole (sis⬘-tah-lee⬙)
circulatory system mitral valve (my⬘-tral) thrombocytes (throm⬘-bow-
diastole (dy-az⬘-tah-lee⬙) myocardium sitez)
endocardium (en-doe-car⬘- pericardium tricuspid valve
dee-um) plasma (plaz⬘-ma) veins
erythrocytes (eh-rith⬘-row-
sitez)

◆ Cardiac Surgeon ◆ Electrocardiographic ◆ Perfusionist
◆ Cardiologist
Technician ◆ Phlebotomist
◆ Hematologist
◆ Cardiovascular ◆ Radiology Technologist
Technologist ◆ Internist
◆ Thoracic Surgeon
◆ Echocardiographer ◆ Medical Laboratory
Technologist/Technician
bon dioxide and metabolic materials away from

7:8 INFORMATION the body cells.
The circulatory system, also known as the car-
diovascular system, is often referred to as the
“transportation” system of the body. It consists of
THE HEART
the heart, blood vessels, and blood. It transports The heart is a muscular, hollow organ often called
oxygen and nutrients to the body cells, and car- the “pump” of the body (figure 7-40). Even though
184 CHAPTER 7
Superior vena cava Aorta

(from upper part of body)
Right pulmonary artery
Left pulmonary artery
Right pulmonary veins Left pulmonary veins
Pulmonary semilunar valve Left atrium
Aortic semilunar valve

Right atrium
Bicuspid (mitral) valve
Tricuspid valve
Left ventricle
Septum
Endocardium
Right ventricle
Myocardium
Pericardium
Inferior vena cava Apex
(from lower part of body)
FIGURE 7-40 Basic structure of the heart.
it weighs less than one pound and is approxi- tum is called the interatrial septum, and the lower
mately the size of a closed fist, it contracts about part is called the interventricular septum.
100,000 times each day to pump the equivalent of The heart is divided into four parts, or cham-
2,000 gallons of blood through the body. The bers. The two upper chambers are called atria,
heart is located in the mediastinal cavity, between and the two lower chambers are called ventricles.
the lungs, behind the sternum, and above the The right atrium receives blood as it returns
diaphragm. Three layers of tissue form the heart. from the body cells. The right ventricle receives
The endocardium is a smooth layer of cells that blood from the right atrium and pumps the blood
lines the inside of the heart and is continuous into the pulmonary artery, which carries the
with the inside of blood vessels. It allows for the blood to the lungs for oxygen. The left atrium
smooth flow of blood. The thickest layer is the receives oxygenated blood from the lungs. The
myocardium, the muscular middle layer. The left ventricle receives blood from the left atrium
pericardium is a double-layered membrane, or and pumps the blood into the aorta for transport
sac, that covers the outside of the heart. A lubri- to the body cells.
cating fluid, pericardial fluid, fills the space One-way valves in the chambers of the heart
between the two layers to prevent friction and keep the blood flowing in the right direction. The
damage to the membranes as the heart beats or tricuspid valve is located between the right
contracts. atrium and the right ventricle. It closes when the
The septum is a muscular wall that separates right ventricle contracts, allowing blood to flow to
the heart into a right side and a left side. It pre- the lungs and preventing blood from flowing back
vents blood from moving between the right and into the right atrium. The pulmonary valve is
left sides of the heart. The upper part of the sep- located between the right ventricle and the pul-
monary artery, a blood vessel that carries blood to of rest, called diastole, followed by a period of
the lungs. It closes when the right ventricle has ventricular contraction, called systole (figure
finished contracting, preventing blood from flow- 7-41). At the start of the cycle, the atria contract and
ing back into the right ventricle. The mitral valve push blood into the ventricles. The atria then relax,
is located between the left atrium and left ventri- and blood returning from the body enters the right
cle. It closes when the left ventricle is contracting, atrium, while blood returning from the lungs enters
allowing blood to flow into the aorta (for transport the left atrium. As the atria are filling, systole begins,
to the body) and preventing blood from flowing and the ventricles contract. The right ventricle
back into the left atrium. The aortic valve is pushes blood into the pulmonary artery, sending
located between the left ventricle and the aorta, the blood to the lungs for oxygen. The left ventricle
the largest artery in the body. It closes when the pushes blood into the aorta, sending the blood to
left ventricle is finished contracting, allowing all other parts of the body. The blood in the right
blood to flow into the aorta and preventing blood side of the heart is low in oxygen and high in car-
from flowing back into the left ventricle. bon dioxide. When this blood arrives in the lungs,
the carbon dioxide is released into the lungs, and
oxygen is taken into the blood. This oxygenated
Cardiac (Heartbeat) Cycle blood is then carried to the left side of the heart by
Although they are separated by the septum, the the pulmonary veins. This blood in the left side of
right and left sides of the heart work together in a the heart, high in oxygen and low in carbon diox-
cyclic manner. The cycle consists of a brief period ide, is ready for transport to the body cells.
Pulmonary circulation
Lungs Gas exchange occurs
at lung capillary beds
Blood to lungs Aorta
Blood from lungs Pulmonary artery
Superior vena cava Pulmonary veins
Pulmonary valve Left atrium
Right atrium Mitral valve
Inferior vena cava Aortic valve
Tricuspid valve Left ventricle
Right ventricle Endocardium
Pericardium Septum
Oxygen-poor blood Myocardium

Gas exchange occurs
Oxygen-rich blood at capillary beds of all
body tissues
Systemic circulation
FIGURE 7-41 The pattern of circulation in the cardiovascular system.
186 CHAPTER 7
Conductive Pathway mately every 0.8 seconds. The movement of the

Electrical impulses originating in the heart cause electrical impulse can be recorded on an electro-
the cyclic contraction of the muscles (figure cardiogram (ECG) and used to detect abnormal
7-42). A group of nerve cells located in the right activity or disease.
atrium and called the sinoatrial (SA) node, or the If something interferes with the normal elec-
“pacemaker,” sends out an electrical impulse that trical conduction pattern of the heart, arrhyth-
spreads out over the muscles in the atria. The mias occur. Arrhythmias are abnormal heart
atrial muscles then contract and push blood into rhythms and can be mild to life-threatening. For
the ventricles. After the electrical impulse passes example, an early contraction of the atria, or pre-
through the atria, it reaches the atrioventricular mature atrial contraction (PAC), can occur in
(AV) node, a group of nerve cells located between anyone and usually goes unnoticed. Ventricle
the atria and ventricles. The AV node sends the fibrillation, in which the ventricles contract at
electrical impulse through the bundle of His, random without coordination, decreases or elim-
nerve fibers in the septum. The bundle of His inates blood output and causes death if not
divides into a right bundle branch and a left bun- treated. Cardiac monitors and electrocardio-
dle branch, which carry the impulse down through grams are used to diagnose arrhythmias. Treat-
the ventricles. The bundle branches further sub- ment depends on the type and severity of the
divide into the Purkinje fibers, a network of nerve arrhythmia. Life-threatening fibrillations are
fibers throughout the ventricles. In this way, the treated with a defibrillator, a device that shocks
electrical impulse reaches all the muscle tissue in the heart with an electrical current to stop the
the ventricles, and the ventricles contract. This uncoordinated contraction and allow the SA node
electrical conduction pattern occurs approxi- to regain control.
Sinoatrial
(SA) node
(pacemaker)
Atrioventricular
bundle (bundle of His)
Atrioventricular
(AV) node
Purkinje fibers
Left and right bundle branches

FIGURE 7-42 Electrical conduction pathways in the heart.
At times it is necessary to use external or inter- Additional branches of the aorta carry blood to
nal artificial pacemakers to regulate the heart’s the head, neck, arms, chest, back, abdomen, and
rhythm, (figure 7-43). The pacemaker is a small, legs. The smallest branches of arteries are called
battery-powered device with electrodes. The elec- arterioles. They join with capillaries. Arteries are
trodes are threaded through a vein and positioned more muscular and elastic than are the other
in the right atrium and in the apex of the right ven- blood vessels because they receive the blood as it
tricle. The pacemaker monitors the heart’s activity is pumped from the heart.
and delivers an electrical impulse through the Capillaries connect arterioles with venules,
electrodes to stimulate contraction. Fixed pace- the smallest veins. Capillaries are located in close
makers deliver electrical impulses at a predeter- proximity to almost every cell in the body. They
mined rate. Demand pacemakers, the most have thin walls that contain only one layer of
common type, deliver electrical impulses only cells. These thin walls allow oxygen and nutrients
when the heart’s own conduction system is not to pass through to the cells and allow carbon
responding correctly. Even though modern pace- dioxide and metabolic products from the cells to
makers are protected from electromagnetic forces, enter the capillaries.
such as microwave ovens, most manufacturers Veins (figure 7-45) are blood vessels that
still recommend that people with pacemakers carry blood back to the heart. Venules, the small-
avoid close contact with digital cellular telephones. est branches of veins, connect with the capillar-
For example, the cellular telephone should not be ies. The venules join together and, becoming
stored in a shirt pocket close to the pacemaker. larger, form veins. The veins continue to join
together until they form the two largest veins: the
superior vena cava and the inferior vena cava.
BLOOD VESSELS The superior vena cava brings the blood from the
upper part of the body, and the inferior vena cava
When the blood leaves the heart, it is carried brings the blood from the lower part of the body.
throughout the body in blood vessels. The heart Both vena cavae drain into the right atrium of the
and blood vessels form a closed system for the heart. Veins are thinner and have less muscle tis-
flow of blood. There are three main types of blood sue than do arteries. Most veins contain valves,
vessels: arteries, capillaries, and veins. which keep the blood from flowing in a backward
Arteries (figure 7-44) carry blood away from direction (figure 7-46).
the heart. The aorta is the largest artery in the
body; it receives the blood from the left ventricle
of the heart. The aorta branches into all of the BLOOD COMPOSITION
other arteries that supply blood to the body. The
first branch of the aorta is the coronary artery, The blood that flows through the circulatory sys-
which divides into a right and left coronary artery tem is often called a tissue because it contains
to carry blood to the myocardium of the heart. many kinds of cells. There are approximately 4–6
quarts of blood in the average adult. This blood
Subclavian vein circulates continuously throughout the body. It
transports oxygen from the lungs to the body
Closed incision
site (covered cells, carbon dioxide from the body cells to the
with occlusive lungs, nutrients from the digestive tract to the
dressing) body cells, metabolic and waste products from
the body cells to the organs of excretion, heat
Subcutaneous produced by various body parts, and hormones
pocket
produced by endocrine glands to the body
Atrial lead
Pacemaker organs.
Superior vena cava
Right atrium Plasma

Right ventricle Ventricular lead Blood is made of the fluid called plasma and
FIGURE 7-43 Artificial pacemakers can help formed or solid elements called blood cells (figure
regulate the heart’s rhythm. 7-47). Plasma is approximately 90 percent water,
188 CHAPTER 7
Right internal carotid
Right external carotid
Left common carotid

Right common carotid
Left subclavian (to arms)

Brachiocephalic
Arch of aorta
Right subclavian
Left axillary
Left brachial
Hepatic
Aorta
Celiac trunk
Splenic
Superior mesenteric Gastric
Renal arteries Left renal (to kidney)

Left testicular/ovarian (gonadal)
Abdominal aorta
Inferior mesenteric
Right common iliac
Left radial
Left ulnar
Right digitals Left deep palmar arch
Left superficial
palmar arch
Right femoral
Left popliteal
Left anterior tibial
Left posterior tibial

Right peroneal
Left dorsalis pedis
Left dorsal arch
FIGURE 7-44 Major arteries of the body.
with many dissolved, or suspended, substances.

Among these substances are blood proteins such
Blood Cells
as fibrinogen and prothrombin (both necessary There are three main kinds of blood cells: eryth-
for clotting); nutrients such as vitamins, carbohy- rocytes, leukocytes, and thrombocytes.
drates, and proteins; mineral salts or electrolytes The erythrocytes, or red blood cells, are
such as potassium, calcium, and sodium; gases produced in the red bone marrow at a rate of
such as carbon dioxide and oxygen; metabolic about one million per minute. They live approxi-
and waste products; hormones; and enzymes. mately 120 days before being broken down by the
Superior sagittal sinus

Inferior sagittal sinus
Straight sinus
Right external jugular Left subclavian
Right internal jugular Great cardiac
Brachiocephalic Left cephalic

Superior vena cava Left axillary
Left basilic
Left brachial
Left hepatic
Right hepatic
Hepatic portal
Splenic
Inferior vena cava
Left renal
Superior mesenteric
Left ovarian or testicular
Right renal
Inferior mesenteric
Right ovarian
or testicular
Left external iliac
Right common iliac
Right palmar arch

Left palmar digitals
Right femoral
Right great saphenous
Left femoral
Left great saphenous
Left popliteal
Right small saphenous
Left posterior tibial
Left anterior tibial
Left dorsal venous arch
FIGURE 7-45 Major veins of the body.
liver and spleen. There are 4.5–5.5 million eryth- is bright red; when blood contains less oxygen
rocytes per cubic millimeter (approximately one and more carbon dioxide, it is a much darker red
drop) of blood, or approximately 25 trillion in the with a bluish cast.
body. The mature form circulating in the blood Leukocytes, or white blood cells, are not as
lacks a nucleus and is shaped like a disk with a numerous as are erythrocytes. They are formed
thinner central area. The erythrocytes contain in the bone marrow and lymph tissue and usually
hemoglobin, a complex protein composed of live about 3–9 days. A normal count is 5,000–9,000
the protein molecule called globin and the iron leukocytes per cubic millimeter of blood. Leuko-
compound called heme. Hemoglobin carries both cytes can pass through capillary walls and enter
oxygen and carbon dioxide. When carrying oxy- body tissue. Their main function is to fight infec-
gen, hemoglobin gives blood its characteristic tion. Some do this by engulfing, ingesting, and
red color. When blood contains a lot of oxygen, it destroying pathogens, or germs, by a process
190 CHAPTER 7
Blood flow toward called phagocytosis. The five types of leukocytes

the heart
and their functions include:
♦ Neutrophils: phagocytize bacteria by secreting
Valve open to an enzyme called lysozyme
allow for venous
blood flow ♦ Eosinophils: remove toxins and defend the
body from allergic reactions by producing
antihistamines
♦ Basophils: participate in the body’s inflamma-
tory response; produce histamine, a vasodila-
tor, and heparin, an anticoagulant
♦ Monocytes: phagocytize bacteria and foreign
materials
Valve closed to ♦ Lymphocytes: provide immunity for the body
prevent venous
back flow by developing antibodies; protect against the
formation of cancer cells
Thrombocytes, also called platelets, are
usually described as fragments or pieces of cells
because they lack nuclei and vary in shape and
size. They are formed in the bone marrow and
live for about 5–9 days. A normal thrombocyte
count is 250,000–400,000 per cubic millimeter of
blood. Thrombocytes are important for the clot-
FIGURE 7-46 Most veins contain valves to ting process, which stops bleeding. When a blood
prevent the backflow of blood.
Plasma
(55% of
Erythrocytes Thrombocytes
total
(platelets)
volume)
Formed
elements
Neutrophil Monocyte
(45% of
total
volume)
Leukocytes
Test tube Eosinophil Lymphocyte

containing
whole blood
Basophil
FIGURE 7-47 The major components of blood.
vessel is cut, the thrombocytes collect at the site ited anemia. It results in the production of abnor-
to form a sticky plug. They secrete a chemical, mal, crescent-shaped erythrocytes that carry less
serotonin, which causes the blood vessel to spasm oxygen, break easily, and block blood vessels (fig-
and narrow, decreasing the flow of blood. At the ure 7-48). Sickle cell anemia occurs almost exclu-
same time, the thrombocytes release an enzyme, sively among African Americans. Treatment
thromboplastin, which acts with calcium and methods include transfusions of packed cells and
other substances in the plasma to form throm- supportive therapy during crisis. Research
bin. Thrombin acts on the blood protein fibrino- directed toward bone marrow transplants, stem
gen to form fibrin, a gel-like net of fine fibers that cell transplants from placental blood, and gene
traps erythrocytes, platelets, and plasma to form cell therapy may offer a cure for sickle cell ane-
a clot. This is an effective method for controlling mia in the near future. Genetic counseling can
bleeding in smaller blood vessels. If a large blood lead to prevention of the disease if carriers make
vessel is cut, the rapid flow of blood can interfere informed decisions not to have children.
with the formation of fibrin. In these instances, a
doctor may have to insert sutures (stitches) to
close the opening and control the bleeding. Aneurysm
An aneurysm is a ballooning out of, or saclike for-
mation on, an artery wall. Disease, congenital
DISEASES AND defects, and injuries leading to weakened arterial
wall structure can cause this defect. Although some
ABNORMAL CONDITIONS aneurysms cause pain and pressure, others gener-
ate no symptoms. Common sites are the cerebral,
Anemia aortal, and abdominal arteries. If an aneurysm rup-
tures, hemorrhage, which can cause death, occurs.
Anemia is an inadequate number of red blood Treatment usually involves surgically removing the
cells, hemoglobin, or both. Symptoms include damaged area of blood vessel and replacing it with
pallor (paleness), fatigue, dyspnea (difficult a plastic graft or another blood vessel.
breathing), and rapid heart rate. Hemorrhage can
cause rapid blood loss, resulting in acute-blood-
loss anemia. Blood transfusions are used to cor- Arteriosclerosis
rect this form of anemia. Iron deficiency anemia
results when there is an inadequate amount of Arteriosclerosis is a hardening or thickening of
iron to form hemoglobin in erythrocytes. Iron the arterial walls, resulting in a loss of elasticity
supplements and increased iron intake in the diet and contractility. It commonly occurs as a result
from green leafy vegetables and other foods can of aging. Arteriosclerosis causes high blood pres-
correct this condition. Aplastic anemia is a result sure, or hypertension, and can lead to an aneu-
of injury to or destruction of the bone marrow, rysm or cerebral hemorrhage. The main focus of
leading to poor or no formation of red blood cells. treatment is lowering blood pressure through the
Common causes include chemotherapy, radia- use of diet, medications, or both.
tion, toxic chemicals, and viruses. Treatment
includes eliminating the cause, blood transfu-
sions, and in severe cases, a bone marrow trans-
plant. Unless the damage can be reversed, it is
frequently fatal. Pernicious anemia results in the
formation of erythrocytes that are abnormally
large in size, but inadequate in number. The
cause is a lack of intrinsic factor (a substance
normally present in the stomach), which results
Normal RBC
in inadequate absorption of vitamin B12. Vitamin
Sickled RBC
B12 and folic acid are required for the develop-
ment of mature erythrocytes. Administering vita-
min B12 injections can control and correct this FIGURE 7-48 Sickle cell anemia is characterized
condition. Sickle cell anemia is a chronic, inher- by abnormal, crescent-shaped erythrocytes.
192 CHAPTER 7
Atherosclerosis may involve either the right side or the left side of
the heart. Symptoms include edema (swelling);
Atherosclerosis occurs when fatty plaques (fre- dypsnea; pallor or cyanosis; distention of the
quently cholesterol) are deposited on the walls of neck veins; a weak, rapid pulse; and a cough
the arteries. This narrows the arterial opening, accompanied by pink, frothy sputum. Cardio-
which reduces or eliminates blood flow. If plaques tonic drugs (to slow and strengthen the heart-
break loose, they can circulate through the blood- beat), diuretics (to remove retained body fluids),
stream as emboli. A low-cholesterol diet, medica- elastic support hose, oxygen therapy, bedrest,
tions to lower cholesterol blood levels, abstaining and/or a low-sodium diet are used as treatment
from smoking, reduction of stress, and exercise methods.
are used to prevent atherosclerosis. Angioplasty
(figure 7-49) may be used to remove or compress
the deposits, or to insert a stent to allow blood
flow. Bypass surgery is used when the arteries are
completely blocked. Embolus
An embolus is a foreign substance circulating in
the bloodstream. It can be air, a blood clot, bacte-
Congestive Heart Failure rial clumps, a fat globule, or other similar sub-
Congestive heart failure (CHF) is a condition that stances. When an embolus enters an artery or
occurs when the heart muscles do not beat ade- capillary too small for passage, blockage of the
quately to supply the blood needs of the body. It blood vessel occurs.
(A) Conventional balloon angioplasty (B) Coronary atherectomy (C) Coronary stent
Atherectomy
Guidewire Balloon catheter Guiding Guidewire Deflated balloon device Stent Balloon
catheter
Cutter
1. In conventional balloon angioplasty, a 1. In coronary atherectomy procedures, a 1. To place a coronary stent within a vessel
guiding catheter is positioned in the opening of special cutting device with a deflated balloon narrowing, physicians use a special catheter
the coronary artery. The physician then pushes on one side and an opening on the other is with a deflated balloon and the stent at the tip.
a thin, flexible guidewire down the vessel and pushed over a wire down the coronary artery.
through the narrowing. The balloon catheter is
then advanced over this guidewire. Inflated balloon
2. The catheter is positioned so that the stent

is within the narrowed region of the coronary
2. When the device is within a coronary artery artery.
2. The balloon catheter is positioned next to the narrowing, the balloon is inflated, so that part
atherosclerotic plaque. of the atherosclerotic plaque is “squeezed”
into the opening of the device.
3. The balloon is then inflated, causing the

stent to expand and stretch the coronary
3. The balloon is inflated stretching and 3. When the physician starts rotating the artery.
cracking the plaque. cutting blade, pieces of plaque are shaved off
into the device.
4. The balloon catheter is then withdrawn,

4. When the balloon is withdrawn, blood flow is 4. The catheter is withdrawn, leaving a larger leaving the stent behind to keep the vessel
re-established through the widened vessel. opening for blood flow. open.
FIGURE 7-49 Ways to open clogged arteries: (A) balloon angioplasty, (B) coronary atherectomy, and (C)
coronary stent.
Hemophilia the arm, neck, and jaw; pressure in the chest; per-
spiration and cold, clammy skin; dypsnea; and a
Hemophilia is an inherited disease that occurs change in blood pressure. If the heart stops, car-
almost exclusively in male individuals but can be diopulmonary resuscitation should be started
carried by female individuals. Because of the lack immediately. Immediate treatment with a throm-
of a plasma protein required for the clotting pro- bolytic or “clot-busting” drug such as streptoki-
cess, the blood is unable to clot. A minor cut can nase or TPA, tissue plasminogen activator, may
lead to prolonged bleeding, and a minor bump open the blood vessel and restore blood flow to
can cause internal bleeding. Treatment involves the heart. However, the clot-busting drug must
transfusing whole blood, or plasma, and admin- be used within the first several hours, and its use
istering the missing protein factor. is prohibited if bleeding is present. Additional
treatment methods include complete bed rest,
pain medications, vasodilators, cardiotonic drugs
Hypertension (to slow and strengthen the heartbeat), oxygen
therapy, anticoagulants (to prevent additional
Hypertension is high blood pressure. A systolic
clots), and control of arrhythmias (abnormal
pressure above 140 and a diastolic pressure above
heart rhythms). Long-term care includes control
90 millimeters of mercury (mmHg) is usually
of blood pressure, a diet low in cholesterol and
regarded as hypertension. Risk factors that
saturated fat, avoidance of tobacco and stress,
increase the incidence of hypertension include
regular exercise, and weight control.
family history, race (higher in African Americans),
obesity, stress, smoking, aging (higher in post-
menopausal women), and a diet high in saturated
fat. Although there is no cure, hypertension can
Phlebitis
usually be controlled with antihypertensive Phlebitis is an inflammation of a vein, frequently
drugs, diuretics (to remove retained body fluids), in the leg. If a thrombus, or clot, forms, the condi-
limited stress, avoidance of tobacco, and/or a tion is termed thrombophlebitis. Symptoms
low-sodium or low-fat diet. If hypertension is not include pain, edema, redness, and discoloration
treated, it can cause permanent damage to the at the site. Treatment methods include anticoag-
heart, blood vessels, and kidneys. ulants; pain medication; elevation of the affected
area; antiembolism or support hose; and if nec-
essary, surgery to remove the clot.
Leukemia
Leukemia is a malignant disease of the bone mar- Varicose Veins
row or lymph tissue. It results in a high number of Varicose veins are dilated, swollen veins that have
immature white blood cells. There are different lost elasticity and cause stasis, or decreased blood
types of leukemia, some acute and some chronic. flow. They frequently occur in the legs and result
Symptoms include fever, pallor, swelling of lym- from pregnancy, prolonged sitting or standing,
phoid tissues, fatigue, anemia, bleeding gums, and hereditary factors. Treatment methods
excessive bruising, and joint pain. Treatment include exercise, antiembolism or support hose,
methods vary with the type of leukemia but can and avoidance of prolonged sitting or standing
include chemotherapy, radiation, and/or bone and tight-fitting or restrictive clothing. In severe
marrow transplant. cases, surgery can be performed to remove the
vein.
Myocardial Infarction STUDENT: Go to the workbook and complete

A myocardial infarction, or heart attack, occurs the assignment sheet for 7:8, Circulatory System.
when a blockage in the coronary arteries cuts off
the supply of blood to the heart. The affected
heart tissue dies and is known as an infarct. Death
can occur immediately. Symptoms include severe
crushing pain (angina pectoris) that radiates to
194 CHAPTER 7
7:9 Lymphatic System ♦ Identify the two lymphatic ducts and the areas
of the body that each drains
Objectives ♦ List at least three functions of the spleen
After completing this section, you should be able ♦ Describe the function of the thymus
to: ♦ Describe at least three diseases of the lym-
♦ Explain the function of lymphatic vessels phatic system
♦ List at least two functions of lymph nodes ♦ Define, pronounce, and spell all key terms
KEY TERMS
cisterna chyli (sis-tern⬘-uh- lymphatic capillaries (lim- spleen
kye⬘-lee) fat⬘-ik) thoracic duct (tho-rass⬘-ik)
lacteals lymphatic system thymus
lymph (limf ⬘) lymphatic vessels tonsils
lymph nodes right lymphatic duct

◆ Immunologist ◆ Internist
7:9 INFORMATION tions of skeletal muscles against the lymph vessels

cause the lymph to flow through the vessels. Lym-
The lymphatic system consists of lymph, phatic vessels also have valves that keep the lymph
lymph vessels, lymph nodes, and lymphatic tis- flowing in only one direction. In the area of the
sue. This system works in conjunction with the small intestine, specialized lymphatic capillaries,
circulatory system to remove wastes and excess called lacteals, pick up digested fats or lipids.
fluids from the tissues (figure 7-50). When lymph is mixed with the lipids it is called
Lymph is a thin, watery fluid composed of chyle. The lacteals transport the chyle to the blood-
intercellular, or interstitial, fluid, which forms stream through the thoracic duct.
when plasma diffuses into tissue spaces. It is Lymph nodes, popularly called “glands,” are
composed of water, digested nutrients, salts, hor- located all over the body, usually in groups or
mones, oxygen, carbon dioxide, lymphocytes, clusters. They are small, round, or oval masses
and metabolic wastes such as urea. When this ranging in size from that of a pinhead to that of an
fluid enters the lymphatic system, it is known as almond. Lymph vessels bring lymph to the nodes.
lymph. The nodes filter the lymph and remove impurities
Lymphatic vessels are located throughout such as carbon, cancer cells, pathogens (disease-
the body in almost all of the tissues that have blood producing organisms), and dead blood cells. In
vessels. Small, open-ended lymph vessels act like addition, the lymphatic tissue in the nodes pro-
drainpipes and are called lymphatic capillar- duces lymphocytes (a type of leukocyte, or white
ies. The lymphatic capillaries pick up lymph at blood cell) and antibodies (substances used to
tissues throughout the body. The capillaries then combat infection). The purified lymph, with lym-
join together to form larger lymphatic vessels, phocytes and antibodies added, leaves the lymph
which pass through the lymph nodes. Contrac- node by a single lymphatic vessel.
Tissue
Lymphatic
cells
capillaries
From heart
An arteriole
Endothelial
cells
Blood capillaries
A venule
Lymph
High blood To heart

pressure pushing out
leaked capillary fluid
FIGURE 7-50 The lymphatic system works with the circulatory system to remove metabolic waste and
excess fluid from the tissues.
Deep cervical Submandibular
lymph nodes lymph node
As lymphatic vessels leave the lymph nodes,
Internal jugular
they continue to join together to form larger Right lymphatic vein
lymph vessels (figure 7-51). Eventually, these ves- duct
sels drain into one of two lymphatic ducts: the Left subclavian
right lymphatic duct or the thoracic duct. The vein
Right
right lymphatic duct is the short tube that subclavian
vein Axillary lymph
receives all of the purified lymph from the right node
side of the head and neck, the right chest, and the
right arm. It empties into the right subclavian
vein, returning the purified lymph to the blood. Thoracic
Intestinal duct *
The thoracic duct, a much larger tube, drains lymph
the lymph from the rest of the body. It empties nodes
into the left subclavian vein. At the start of the
Iliac nodes
thoracic duct, an enlarged pouchlike structure
called the cisterna chyli serves as a storage area
for purified lymph before this lymph returns to
the bloodstream. The cisterna chyli also receives
chyle from the intestinal lacteals.
In addition to being found in the lymph
nodes, lymphatic tissue is located throughout the
body. The tonsils, spleen, and thymus are exam-
ples of lymphatic tissue.
The tonsils are masses of lymphatic tissue
* Largest lymph
that filter interstitial fluid. There are three pairs of vessel in body
Inguinal lymph
tonsils: nodes
♦ Palatine tonsils: located on each side of the FIGURE 7-51 Main components of the lymphatic
soft palate system.
196 CHAPTER 7
♦ Pharyngeal tonsils: (also called adenoids) ritus (itching). Chemotherapy and radiation are
located in the nasopharynx (the upper part of usually effective forms of treatment.
the throat)
♦ Lingual tonsils: located on the back of the Lymphangitis
tongue
Lymphangitis is an inflammation of lymphatic
The spleen is an organ located beneath the vessels, usually resulting from an infection in an
left side of the diaphragm and in back of the extremity. Symptoms include a characteristic red
upper part of the stomach. It produces leukocytes streak extending up an arm or leg from the source
and antibodies, destroys old erythrocytes (red of infection, fever, chills, and tenderness or pain.
blood cells), stores erythrocytes to release into Treatment methods include antibiotics, rest, ele-
the bloodstream if excessive bleeding occurs, vation of the affected part, and/or warm, moist
destroys thrombocytes (platelets), and filters compresses.
metabolites and wastes from body tissues.
The thymus is a mass of lymph tissue located
in the center of the upper chest. It atrophies Splenomegaly
(wastes away) after puberty and is replaced by fat Splenomegaly is an enlargement of the spleen. It
and connective tissue. During early life, it pro- can result from an abnormal accumulation of red
duces antibodies and manufactures lymphocytes blood cells, mononucleosis, and cirrhosis of the
to fight infection. Its function is taken over by the liver. The main symptoms are swelling and
lymph nodes. abdominal pain. An increased destruction of
blood cells can lead to anemia (low red blood cell
count), leukopenia (low white blood cell count),
DISEASES AND and thrombocytopenia (low thrombocyte count).
If the spleen ruptures, intraperitoneal hemor-
ABNORMAL CONDITIONS rhage and shock can lead to death. In severe
cases, where the underlying cause cannot be
Adenitis treated, a splenectomy (surgical removal of the
spleen) is performed.
Adenitis is an inflammation or infection of the
lymph nodes. It occurs when large quantities of
harmful substances, such as pathogens or cancer
cells, enter the lymph nodes and infect the tissue.
Tonsillitis
Symptoms include fever and swollen, painful Tonsillitis is an inflammation or infection of the
nodes. If the infection is not treated, an abscess tonsils. It usually involves the pharyngeal (ade-
may form in the node. Usually treatment meth- noid) and palatine tonsils. Symptoms include
ods are antibiotics and warm, moist compresses. throat pain, dysphagia (difficulty swallowing),
If an abscess forms, it is sometimes necessary to fever, white or yellow spots of exudate on the ton-
incise and drain the node. sils, and swollen lymph nodes near the mandible.
Antibiotics, warm throat irrigations, rest, and
analgesics for pain are the main forms of treat-
ment. Chronic, frequent infections or hypertro-
Hodgkin’s Disease phy (enlargement) that causes obstruction are
Hodgkin’s disease is a chronic, malignant disease indications for a tonsillectomy, or surgical
of the lymph nodes. It is the most common form removal of the tonsils.
of lymphoma (tumor of lymph tissue). Symptoms
include painless swelling of the lymph nodes, STUDENT: Go to the workbook and complete
fever, night sweats, weight loss, fatigue, and pru- the assignment sheet for 7:9, Lymphatic System.
7:10 Respiratory System ♦ Describe the function of the epiglottis

♦ Compare the processes of inspiration and
Objectives expiration, including the muscle action that
After completing this section, you should be able occurs during each process
to: ♦ Differentiate between external and internal
♦ Label a diagram of the respiratory system respiration
♦ List five functions of the nasal cavity ♦ Describe at least five diseases of the respira-
tory system
♦ Identify the three sections of the pharynx
♦ Explain how the larynx helps create sound
and speech
KEY TERMS
alveoli (ahl-vee⬘-oh⬙-lie) inspiration pleura
bronchi (bron⬘-kie) internal respiration respiration
bronchioles (bron⬘-key⬙-ohlz) larynx (lar⬘-inks) respiratory system (res⬘-peh-
cellular respiration lungs reh-tor⬘-ee)
cilia (sil⬘-lee-ah) nasal cavities sinuses
epiglottis (ep-ih-glot⬘-tiss) nasal septum trachea (tray⬘-key⬙-ah)
expiration nose ventilation
external respiration pharynx (far⬘-inks)

◆ Internist ◆ Pulmonologist ◆ Respiratory Therapy
◆ Otolaryngologist ◆ Respiratory Therapist
Technician
◆ Thoracic Surgeon
◆ Perfusionist
7:10 INFORMATION RESPIRATORY ORGANS

The respiratory system consists of the lungs
and air passages. This system is responsible for
AND STRUCTURES
taking in oxygen, a gas needed by all body cells, The nose has two openings, called nostrils or
and removing carbon dioxide, a gas that is a met- nares, through which air enters. A wall of carti-
abolic waste product produced by the cells when lage, called the nasal septum, divides the nose
the cells convert food into energy. Because the into two hollow spaces, called nasal cavities.
body has only a 4–6-minute supply of oxygen, the The nasal cavities are lined with a mucous mem-
respiratory system must work continuously to brane and have a rich blood supply. As air enters
prevent death. the cavities, it is warmed, filtered, and moistened.
The parts of the respiratory system are the Mucus, produced by the mucous membranes,
nose, pharynx, larynx, trachea, bronchi, alveoli, moistens the air and helps trap pathogens and
and lungs (figure 7-52). dirt. Tiny, hairlike structures, called cilia, filter
198 CHAPTER 7
Sinuses
Nasal cavity
Nostril
Oral cavity
Tongue Pharynx
Epiglottis
Larynx (voice box) Esophagus
Right lung
Superior
(upper) lobe Trachea
Left lung
Visceral
Bronchial tree
pleura Left bronchus
Pleural cavity Bronchiole

Parietal pleura Alveoli
Middle lobe
Inferior (lower)
lobe
Diaphragm
Bronchiole
Esophagus
Mediastinum
Terminal
bronchiole
Alveolar duct
Capillaries
surrounding
alveoli
Alveolar
Alveoli
sac
FIGURE 7-52 The respiratory system.
inhaled air to trap dust and other particles. The sections. The nasopharynx is the upper portion,
cilia then help move the mucous layer that lines located behind the nasal cavities. The pharyngeal
the airways to push trapped particles toward the tonsils, or adenoids (lymphatic tissue), and the
esophagus, where they can be swallowed. The eustachian tube (tube to middle ear) openings
olfactory receptors for the sense of smell are also are located in this section. The oropharynx is the
located in the nose. The nasolacrimal ducts drain middle section, located behind the oral cavity
tears from the eye into the nose to provide addi- (mouth). This section receives both air from
tional moisture for the air. the nasopharynx and food and air from the
Sinuses are cavities in the skull that sur- mouth. The laryngopharynx is the bottom sec-
round the nasal area. They are connected to the tion of the pharynx. The esophagus, which car-
nasal cavity by short ducts. The sinuses are lined ries food to the stomach, and the trachea, which
with a mucous membrane that warms and moist- carries air to and from the lungs, branch off the
ens air. The sinuses also provide resonance for laryngopharynx.
the voice. The larynx, or voice box, lies between the
The pharynx, or throat, lies directly behind pharynx and trachea. It has nine layers of carti-
the nasal cavities. As air leaves the nose, it enters lage. The largest, the thyroid cartilage, is com-
the pharynx. The pharynx is divided into three monly called the Adam’s apple. The larynx
contains two folds, called vocal cords. The open-

ing between the vocal cords is called the glottis. PROCESS OF
As air leaves the lungs, the vocal cords vibrate
and produce sound. The tongue and lips act on
BREATHING
the sound to produce speech. The epiglottis, Ventilation is the process of breathing. It
a special leaflike piece of cartilage, closes the involves two phases: inspiration and expiration.
opening into the larynx during swallowing. This Inspiration (inhalation) is the process of breath-
prevents food and liquids from entering the respi- ing in air. The diaphragm (dome-shaped muscle
ratory tract. between the thoracic and abdominal cavities)
The trachea (windpipe) is a tube extending and the intercostal muscles (between the ribs)
from the larynx to the center of the chest. It car- contract and enlarge the thoracic cavity to create
ries air between the pharynx and the bronchi. A a vacuum. Air rushes in through the airways to
series of C-shaped cartilages (which are open on the alveoli, where the exchange of gases takes
the dorsal, or back, surfaces) help keep the tra- place. When the diaphragm and intercostal mus-
chea open. cles relax, the process of expiration (exhalation)
The trachea divides into two bronchi near occurs. Air is forced out of the lungs and air pas-
the center of the chest, a right bronchus and a left sages. This process of inspiration and expiration
bronchus. The right bronchus is shorter, wider, is known as respiration. The process of respira-
and extends more vertically than the left bron- tion is controlled by the respiratory center in the
chus. Each bronchus enters a lung and carries air medulla oblongata of the brain. An increased
from the trachea to the lung. In the lungs, the amount of carbon dioxide in the blood, or a
bronchi continue to divide into smaller and decreased amount of oxygen as seen in certain
smaller bronchi until, finally, they divide into diseases (asthma, congestive heart failure, or
the smallest branches, called bronchioles. The emphysema), causes the center to increase the
smallest bronchioles, called terminal bronchi- rate of respiration. Although this process is usu-
oles, end in air sacs, called alveoli. ally involuntary, a person can control the rate of
The alveoli resemble a bunch of grapes. An breathing by breathing faster or slower.
adult lung contains approximately 500 million
alveoli. They are made of one layer of squamous
epithelial tissue and contain a rich network of
blood capillaries. The capillaries allow oxygen STAGES OF
and carbon dioxide to be exchanged between the
blood and the lungs. The inner surfaces of the
RESPIRATION
alveoli are covered with a lipid (fatty) substance, There are two main stages of respiration: external
called surfactant, to help prevent them from col- respiration and internal respiration (figure 7-53).
lapsing. External respiration is the exchange of oxygen
The divisions of the bronchi and the alveoli and carbon dioxide between the lungs and blood-
are found in organs called lungs. The right lung stream. Oxygen, breathed in through the respira-
has three sections, or lobes: the superior, the tory system, enters the alveoli. Because the
middle, and the inferior. The left lung has only oxygen concentration in the alveoli is higher than
two lobes: the superior and the inferior. The left the oxygen concentration in the blood capillar-
lung is smaller because the heart is located toward ies, oxygen leaves the alveoli and enters the capil-
the left side of the chest. Each lung is enclosed in laries and the bloodstream. Carbon dioxide, a
a membrane, or sac, called the pleura. The metabolic waste product, is carried in the blood-
pleura consists of two layers of serous membrane: stream. Because the carbon dioxide concentra-
a visceral pleura attached to the surface of the tion in the capillaries is higher than the carbon
lung, and a parietal pleura attached to the chest dioxide concentration in the alveoli, carbon diox-
wall. A pleural space, located between the two ide leaves the capillaries and enters the alveoli,
layers, is filled with a thin layer of pleural fluid where it is expelled from the body during exhala-
that lubricates the membranes and prevents friction. Internal respiration is the exchange of
tion as the lungs expand during breathing. Both carbon dioxide and oxygen between the tissue
of the lungs, along with the heart and major blood cells and the bloodstream. Oxygen is carried to
vessels, are located in the thoracic cavity. the tissue cells by the blood. Because the oxygen
200 CHAPTER 7
Air sucked in Airways of respiratory

tree (ventilation)
Air blown out
Alveoli
O2
External respiration (gas exchange between air in

alveoli and blood in pulmonary capillaries)
CO2
Tissue cells
Blood in
pulmonary capillaries
Blood flow
CO2
O2
Internal
Blood in
respiration
systemic capillaries
(gas exchange
between tissue
Blood flow cells
and blood in
systemic
capillaries)
FIGURE 7-53 External and internal respiration.
concentration is higher in the blood than in the ertion, and infection can also cause an asthma
tissue cells, oxygen leaves the blood capillaries attack, during which bronchospasms narrow the
and enters the tissue cells. The cells then use the openings of the bronchioles, mucus production
oxygen and nutrients to produce energy, water, increases, and edema develops in the mucosal
and carbon dioxide. This process is called cellu- lining. Symptoms of an asthma attack include
lar respiration. Because the carbon dioxide dyspnea (difficult breathing), wheezing, cough-
concentration is higher in tissue cells than in the ing accompanied by expectoration of sputum,
bloodstream, carbon dioxide leaves the cells and and tightness in the chest. Treatment methods
enters the bloodstream to be transported back to include bronchodilators (to enlarge the bronchi-
the lungs, where external respiration takes place. oles), anti-inflammatory medications, epineph-
rine, and oxygen therapy. Identification and
elimination of or disensitization to allergens are
DISEASES AND important in preventing asthma attacks.
ABNORMAL CONDITIONS
Bronchitis
Asthma Bronchitis is an inflammation of the bronchi and
Asthma is a respiratory disorder usually caused bronchial tubes. Acute bronchitis is usually caused
by a sensitivity to an allergen such as dust, pollen, by infection and is characterized by a productive
an animal, medications, or a food. Stress, overex- cough, dyspnea, rales (bubbly or noisy breath
sounds), chest pain, and fever. It is treated with

antibiotics, expectorants (to remove excessive
mucus), rest, and drinking large amounts of water.
Chronic bronchitis results from frequent attacks of
acute bronchitis and long-term exposure to pollut-
ants or smoking. It is characterized by chronic
inflammation, damaged cilia, and enlarged mucous
glands. Symptoms include excessive mucus result-
ing in a productive cough, wheezing, dyspnea, chest
pain, and prolonged air expiration. Although there
is no cure, antibiotics, bronchodilators, and/or
respiratory therapy are used in treatment.
Chronic Obstructive
Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is
a term used to describe any chronic lung disease
that results in obstruction of the airways. Disorders
such as chronic asthma, chronic bronchitis, emphy-
sema, and tuberculosis lead to COPD. Smoking is
Images not available due to copyright restrictions
the primary cause, but allergies and chronic respi-
ratory infections are also factors. Treatment meth-
ods include bronchodilators, mucolytics (loosen
mucus secretions), and cough medications. The
prognosis is poor because damage to the lungs
causes a deterioration of pulmonary function, lead-
ing to respiratory failure and death.
Emphysema
Emphysema is a noninfectious, chronic respira-
tory condition that occurs when the walls of the
alveoli deteriorate and lose their elasticity (figure
7-54). Carbon dioxide remains trapped in the alve-
oli, and there is poor exchange of gases. The most
common causes are heavy smoking and prolonged
exposure to air pollutants. Symptoms include dys-
pnea, a feeling of suffocation, pain, barrel chest,
chronic cough, cyanosis, rapid respirations accom-
panied by prolonged expirations, and eventual
respiratory failure and death. Although there is no
cure, treatment methods include bronchodilators,
breathing exercises, prompt treatment of respira-
tory infections, oxygen therapy, respiratory ther-
apy, and avoidance of smoking. tension, chronic infection, anticoagulant drugs,
and blood diseases such as hemophilia and leu-
kemia. Compressing the nostrils toward the sep-
Epistaxis tum; elevating the head and tilting it slightly
Epistaxis, or a nosebleed, occurs when capillaries forward; and applying cold compresses will usu-
in the nose become congested and bleed. It can ally control epistaxis, although it is sometimes
be caused by an injury or blow to the nose, hyper- necessary to insert nasal packs or cauterize (burn
202 CHAPTER 7
and destroy) the bleeding vessels. Treatment of Pleurisy

any underlying cause, such as hypertension, is
important in preventing epistaxis. Pleurisy is an inflammation of the pleura, or
membranes, of the lungs. It usually occurs in
conjunction with pneumonia or other lung infec-
Influenza tions. Symptoms include sharp, stabbing pain
while breathing; crepitation (grating sounds in
Influenza, or flu, is a highly contagious viral infec- the lungs); dyspnea; and fever. Treatment meth-
tion of the upper respiratory system. Onset is ods include rest and medications to relieve pain
sudden, and symptoms include chills, fever, a and inflammation. If fluid collects in the pleural
cough, sore throat, runny nose, muscle pain, and space, a thoracentesis (withdrawal of fluid through
fatigue. Treatment methods include bed rest, flu- a needle) is performed to remove the fluid and
ids, analgesics (for pain), and antipyretics (for prevent compression of the lungs.
fever). Antibiotics are not effective against the
viruses that cause influenza, but they are some-
times given to prevent secondary infections such Pneumonia
as pneumonia. Immunization with a flu vaccine Pneumonia is an inflammation or infection of the
is recommended for the elderly, individuals with lungs characterized by exudate (a buildup of fluid)
chronic diseases, pregnant women, and health in the alveoli. It is usually caused by bacteria,
care workers. Because many different viruses viruses, protozoa, or chemicals. Symptoms include
cause influenza, vaccines are developed each chills, fever, chest pain, productive cough, dyspnea,
year to immunize against the most common and fatigue. Treatment methods include bed rest,
viruses identified. oxygen therapy, fluids, antibiotics (if indicated),
respiratory therapy, and/or pain medication.
Laryngitis
Laryngitis is an inflammation of the larynx and Rhinitis
vocal cords. It frequently occurs in conjunction Rhinitis is an inflammation of the nasal mucous
with other respiratory infections. Symptoms membrane, resulting in a runny nose, watery eyes,
include hoarseness or loss of voice, sore throat, sneezing, soreness, and congestion. Common
and dysphagia (difficult swallowing). Treatment causes are infections and allergens. Treatment con-
methods include rest, limited voice use, fluids, sists of administering fluids and medications to
and medication, if an infection is present. relieve congestion. Rhinitis is usually self-limiting.
Lung Cancer Sinusitis

Lung cancer is the leading cause of cancer death Sinusitis is an inflammation of the mucous mem-
in both men and women (figure 7-54). It is a brane lining the sinuses. One or more sinuses
preventable disease because the main cause is may be affected. Sinusitis is usually caused by a
exposure to carcinogens in tobacco, either bacterium or virus. Symptoms include headache
through smoking or through exposure to “sec- or pressure, dizziness, thick nasal discharge, con-
ond-hand” smoke. Three common types of lung gestion, and loss of voice resonance. Treatment
cancer include small cell, squamous cell, and methods include analgesics (for pain), antibiot-
adenocarcinoma. In the early stages, there are no ics (if indicated), decongestants (medications to
symptoms. In later stages, symptoms include a loosen secretions), and moist inhalations. Sur-
chronic cough, hemoptysis (coughing up blood- gery is used in cases of chronic sinusitis to open
tinged sputum), dyspnea, fatigue, weight loss, the cavities and encourage drainage.
and chest pain. The prognosis (outcome) for lung
cancer patients is poor because the disease is
usually advanced before it is diagnosed. Treat-
Sleep Apnea
ment includes surgical removal of the cancerous Sleep apnea is a condition in which an individ-
sections of the lung, radiation, and/or chemo- ual stops breathing while asleep, causing a mea-
therapy. surable decrease in blood oxygen levels. There
are two main kinds of sleep apnea: obstructive

and central. Obstructive sleep apnea is caused by
a blockage in the air passage that occurs when
the muscles that keep the airway open relax and
allow the tongue and palate to block the airway.
Central sleep apnea is caused by a disorder in
the respiratory control center of the brain. The
condition is more common in men. Factors such
as obesity, hypertension, smoking, alcohol
ingestion, and/or the use of sedatives may
increase the severity. Sleep apnea is diagnosed
when more than 5 periods of apnea lasting at
least 10 seconds each occur during 1 hour of
sleep. The periods of apnea reduce the blood FIGURE 7-55 The continuous positive airway
oxygen level. This causes the brain to awaken pressure (CPAP) mask attaches to a blower device
the individual, who then gasps for air and snores that uses air pressure to keep the airway open and
loudly. This interruption of the sleep cycle leads prevent sleep apnea.
to excessive tiredness and drowsiness during the
day. Treatment involves losing weight, abstain-
ing from smoking and the use of alcohol or sed- Upper Respiratory Infection
atives, and sleeping on the side or stomach. In
An upper respiratory infection (URI), or common
more severe cases of obstructive sleep apnea, a
cold, is an inflammation of the mucous mem-
continuous positive airway pressure, or CPAP
brane lining the upper respiratory tract. Caused
(pronounced see-pap), is used to deliver pres-
by viruses, URIs are highly contagious. Symptoms
sure to the airway to keep the airway open while
include fever, runny nose, watery eyes, conges-
the individual sleeps (figure 7-55). The CPAP
tion, sore throat, and hacking cough. There is no
consists of a mask that is fit securely against the
cure, and symptoms usually last approximately
face. Tubing connects the mask with a blower
one week. Analgesics (for pain), antipyretics (for
device that can be adjusted to deliver air at dif-
fever), rest, increased fluid intake, and antihista-
ferent levels of pressure. Treatment of central
mines (to relieve congestion) are used to treat the
sleep apnea usually involves the use of medica-
symptoms.
tions to stimulate breathing.
the assignment sheet for 7:10, Respiratory System.
Tuberculosis
Tuberculosis (TB) is an infectious lung disease 7:11 Digestive System
caused by the bacterium Mycobacterium tuber-
culosis. At times, white blood cells surround the Objectives
invading TB organisms and wall them off, creat- After completing this section, you should be able
ing nodules, called tubercles, in the lungs. The TB to:
organisms remain dormant in the tubercles but
can cause an active case of TB later, if body resis- ♦ Label the major organs on a diagram of the
tance is lowered. Symptoms of an active case of digestive system
TB include fatigue, fever, night sweats, weight ♦ Identify at least three organs that are located
loss, hemoptysis (coughing up blood-tinged spu- in the mouth and aid in the initial breakdown
tum), and chest pain. Treatment includes admin- of food
istering drugs for one or more years to destroy ♦ Cite two functions of the salivary glands
the bacteria. Good nutrition and rest are also
important. In recent years, a new strain of the TB ♦ Describe how the gastric juices act on food in
bacteria resistant to drug therapy has created the stomach
concern that TB will become a widespread infec- ♦ Explain how food is absorbed into the body by
tious disease. the villi in the small intestine
204 CHAPTER 7
♦ List at least three functions of the large intes- ♦ Describe at least five diseases of the digestive
tine system
♦ List at least four functions of the liver ♦ Define, pronounce, and spell all key terms
♦ Explain how the pancreas helps digest foods
KEY TERMS
alimentary canal (ahl-ih- hard palate rectum
men⬘-tar⬙-ee) ileum (ill⬘-ee⬙-um) salivary glands
anus jejunum (jeh-jew⬘-num) small intestine
colon (coh⬘-lun) large intestine soft palate
digestive system liver stomach
duodenum (dew-oh-deh⬘- mouth teeth
num) pancreas (pan⬘-cree⬙-as) tongue
esophagus (ee⬙-sof⬘-eh-gus) peristalsis (pair⬙-ih-stall⬙-sis) vermiform appendix
gallbladder pharynx (far⬘-inks) villi (vil⬘-lie)

◆ Dental Assistant ◆ Dietitian ◆ Hepatologist
◆ Dental Hygienist ◆ Enterostomal RN or ◆ Internist
◆ Dentist
Technician ◆ Proctologist
◆ Gastroenterologist
◆ Dietetic Assistant
7:11 INFORMATION PARTS OF THE

The digestive system, also known as the gastro-
ALIMENTARY CANAL
intestinal system, is responsible for the physical The mouth, also called the buccal cavity (figure
and chemical breakdown of food so that it can be 7-57) receives food as it enters the body. While
taken into the bloodstream and used by body food is in the mouth, it is tasted, broken down
cells and tissues. The system consists of the physically by the teeth, lubricated and partially
alimentary canal and accessory organs (figure digested by saliva, and swallowed. The teeth are
7-56). The alimentary canal is a long, muscular special structures in the mouth that physically
tube that begins at the mouth and includes the break down food by chewing and grinding. This
mouth (oral cavity), pharynx, esophagus, stom- process is called mastication. The tongue is a
ach, small intestine, large intestine, and anus. muscular organ that contains special receptors
The accessory organs are the salivary glands, called taste buds. The taste buds allow a person to
tongue, teeth, liver, gallbladder, and pancreas. taste sweet, salty, sour, and bitter sensations. The
Oral cavity
Parotid gland
Lips
Teeth Pharynx
Submandibular
Tongue gland
Sublingual gland
Esophagus
Diaphragm Stomach
Hepatic duct
Liver
Pylorus of the
Cystic duct stomach
Gallbladder Pancreas
Transverse colon
of large intestine
Duodenum
Jejunum of
Ascending colon of large intestine small intestine
Descending
colon of large
Ileum of small intestine intestine
Sigmoid colon
of large intestine
Cecum
Rectum
Vermiform appendix
Anus
FIGURE 7-56 The digestive system.
tongue also aids in chewing and swallowing food. down of carbohydrates, or starches, into sugars
The hard palate is the bony structure that forms that can be taken into the body.
the roof of the mouth and separates the mouth After the food is chewed and mixed with
from the nasal cavities. Behind the hard palate is saliva, it is called a bolus. When the bolus is swal-
the soft palate, which separates the mouth from lowed, it enters the pharynx (throat). The phar-
the nasopharynx. The uvula, a cone-shaped ynx is a tube that carries both air and food. It
muscular structure, hangs from the middle of the carries the air to the trachea, or windpipe, and
soft palate. It prevents food from entering the food to the esophagus. When a bolus is being
nasopharynx during swallowing. Three pairs of swallowed, muscle action causes the epiglottis to
salivary glands, the parotid, sublingual, and close over the larynx, preventing the bolus from
submandibular, produce a liquid called saliva. entering the respiratory tract and causing it to
Saliva lubricates the mouth during speech and enter the esophagus.
chewing and moistens food so that it can be swal- The esophagus is the muscular tube dorsal
lowed easily. Saliva also contains an enzyme (a to (behind) the trachea. This tube receives the
substance that speeds up a chemical reaction) bolus from the pharynx and carries the bolus to
called salivary amylase, formerly known as ptya- the stomach. The esophagus, like the remaining
lin. Salivary amylase begins the chemical break- part of the alimentary canal, relies on a rhythmic,
206 CHAPTER 7
mentary canal. It is approximately 20 feet in

Gum (gingiva) Upper lip length and 1 inch in diameter, and is divided into
three sections: the duodenum, the jejunum, and
the ileum. The duodenum is the first 9–10 inches
Labial frenulum
of the small intestine. Bile (from the gallbladder
Hard
and liver) and pancreatic juice (from the pan-
palate creas) enter this section through ducts, or tubes.
Palatine tonsil
The jejunum is approximately 8 feet in length
Soft and forms the middle section of the small intes-
palate tine. The ileum is the final 12 feet of the small
intestine, and it connects with the large intestine
Uvula
at the cecum. The circular muscle called the ileo-
Lingual frenulum
cecal valve separates the ileum and cecum and
Tongue prevents food from returning to the ileum. While
food is in the small intestine, the process of diges-
Teeth tion is completed, and the products of digestion
Gum (gingiva) are absorbed into the bloodstream for use by the
body cells. Intestinal juices, produced by the
Lower lip Labial frenulum small intestine, contain the enzymes maltase,
sucrase, and lactase, which break down sugars
FIGURE 7-57 Parts of the oral cavity, or mouth. into simpler forms. The intestinal juices also con-
tain enzymes known as peptidases, which com-
wavelike, involuntary movement of its muscles plete the digestion of proteins, and steapsin
called peristalsis to move the food in a forward (lipase), which aids in the digestion of fat. Bile
direction. from the liver and gallbladder emulsifies (physi-
The stomach is an enlarged part of the ali- cally breaks down) fats. Enzymes from the pan-
mentary canal. It receives the food from the creatic juice complete the process of digestion.
esophagus. The mucous membrane lining of the These enzymes include pancreatic amylase or
stomach contains folds, called rugae. These dis- amylopsin (which acts on sugars), trypsin and
appear as the stomach fills with food and expands. chymotrypsin (which act on proteins), and lipase
The cardiac sphincter, a circular muscle between or steapsin (which acts on fats). After food has
the esophagus and stomach, closes after food been digested, it is absorbed into the blood-
enters the stomach and prevents food from going stream. The walls of the small intestine are lined
back up into the esophagus. The pyloric sphinc- with fingerlike projections called villi (figure
ter, a circular muscle between the stomach and 7-58). The villi contain blood capillaries and lac-
small intestine, keeps food in the stomach until teals. The blood capillaries absorb the digested
the food is ready to enter the small intestine. Food nutrients and carry them to the liver, where they
usually remains in the stomach for approximately are either stored or released into general circula-
2–4 hours. During this time, food is converted tion for use by the body cells. The lacteals absorb
into a semifluid material, called chyme, by gastric most of the digested fats and carry them to the
juices produced by glands in the stomach. The thoracic duct in the lymphatic system, which
gastric juices contain hydrochloric acid and releases them into the circulatory system. When
enzymes. Hydrochloric acid kills bacteria, facili- food has completed its passage through the small
tates iron absorption, and activates the enzyme intestine, only wastes, indigestible materials, and
pepsin. The enzymes in gastric juices include excess water remain.
lipase, which starts the chemical breakdown of The large intestine is the final section of
fats, and pepsin, which starts protein digestion. the alimentary canal. It is approximately 5 feet in
In infants, the enzyme rennin is also secreted to length and 2 inches in diameter. Functions
aid in the digestion of milk. Rennin is not present include absorption of water and any remaining
in adults. nutrients; storage of indigestible materials before
When the food, in the form of chyme, leaves they are eliminated from the body; synthesis (for-
the stomach, it enters the small intestine. The mation) and absorption of some B-complex vita-
small intestine is a coiled section of the ali- mins and vitamin K by bacteria present in the
Capillary network
in villus
Lacteal
Epithelial
cells
Intestinal
gland
Artery
Vein
Lymph
vessel
Circular
muscles
Longitudinal
muscles
Peritoneum
FIGURE 7-58 Lymphatic and blood capillaries in the villi of the small intestine provide for the absorption of
the products of digestion.
intestine; and transportation of waste products Left lobe of liver
out of the alimentary canal. The large intestine is
divided into a series of connected sections. The Right hepatic
cecum is the first section and is connected to the duct
ileum of the small intestine. It contains a small Cystic
projection, called the vermiform appendix. duct
The next section, the colon, has several divi- Left hepatic duct
sions. The ascending colon continues up on the
Common hepatic duct
right side of the body from the cecum to the lower Gallbladder
part of the liver. The transverse colon extends
across the abdomen, below the liver and stomach Tail of
and above the small intestine. The descending pancreas
colon extends down the left side of the body. It
connects with the sigmoid colon, an S-shaped Common bile duct
section that joins with the rectum. The rectum is Main pancreatic
the final 6–8 inches of the large intestine and is a Head of
duct
pancreas
storage area for indigestibles and wastes. It has a
narrow canal, called the anal canal, which opens
Duodenum
at a hole, called the anus. Fecal material, or stool, Sphincter
the final waste product of the digestive process, is of Oddi
expelled through this opening. FIGURE 7-59 The liver, gallbladder, and
pancreas.
ACCESSORY ORGANS soluble, which is necessary for absorption. The

liver stores sugar in the form of glycogen. The gly-
The liver (figure 7-59), is the largest gland in the cogen is converted to glucose and released into
body and is an accessory organ to the digestive the bloodstream when additional blood sugar is
system. It is located under the diaphragm and in needed. The liver also stores iron and certain
the upper right quadrant of the abdomen. The vitamins. It produces heparin, which prevents
liver secretes bile, which is used to emulsify fats clotting of the blood; blood proteins such as
in the digestive tract. Bile also makes fats water fibrinogen and prothrombin, which aid in clot-
208 CHAPTER 7
ting of the blood; and cholesterol. Finally, the pain that starts under the rib cage and radiates to
liver detoxifies (renders less harmful) substances the right shoulder. If a gallstone blocks the bile
such as alcohol and pesticides, and destroys bac- ducts, the gallbladder can rupture and cause
teria that have been taken into the blood from peritonitis. Treatment methods include a low-fat
the intestine. diet, lithotripsy (shock waves that are used to
The gallbladder is a small, muscular sac shatter the gallstones), and/or a cholecystectomy
located under the liver and attached to it by con- (surgical removal of the gallbladder).
nective tissue. It stores and concentrates bile,
which it receives from the liver. When the bile is
needed to emulsify fats in the digestive tract, the Cirrhosis
gallbladder contracts and pushes the bile through Cirrhosis is a chronic destruction of liver cells
the cystic duct into the common bile duct, which accompanied by the formation of fibrous connec-
drains into the duodenum. tive and scar tissue. Causes include hepatitis, bile
The pancreas is a glandular organ located duct disease, chemical toxins, and malnutrition
behind the stomach. It produces pancreatic associated with alcoholism. Symptoms vary and
juices, which contain enzymes to digest food. become more severe as the disease progresses.
These juices enter the duodenum through the Some common symptoms are liver enlargement,
pancreatic duct. The enzymes in the juices anemia, indigestion, nausea, edema in the legs
include pancreatic amylase or amylopsin (to and feet, hematemesis (vomiting blood), nose-
break down sugars), trypsin and chymotrypsin bleeds, jaundice (yellow discoloration), and asci-
(to break down proteins), and lipase or steapsin tes (an accumulation of fluid in the abdominal
(to act on fats). The pancreas also produces insu- peritoneal cavity). When the liver fails, disorienta-
lin, which is secreted into the bloodstream. Insu- tion, hallucinations, hepatic coma, and death
lin regulates the metabolism, or burning, of occur. Treatment is directed toward preventing
carbohydrates to convert glucose (blood sugar) further damage to the liver. Alcohol avoidance,
to energy. proper nutrition, vitamin supplements, diuretics
(to reduce ascites and edema), rest, infection pre-
vention, and appropriate exercise are encouraged.
DISEASES AND A liver transplant may be performed if too much of
the liver is destroyed.
ABNORMAL CONDITIONS
Appendicitis Constipation
Appendicitis is an acute inflammation of the Constipation is when fecal material remains in the
appendix, usually resulting from an obstruction colon too long, causing excessive reabsorption of
and infection. Symptoms include generalized water. The feces or stool becomes hard, dry, and
abdominal pain that later localizes at the lower difficult to eliminate. Causes include poor bowel
right quadrant, nausea and vomiting, mild fever, habits, chronic laxative use leading to a “lazy”
and elevated white blood cell count. If the appen- bowel, a diet low in fiber, and certain digestive dis-
dix ruptures, the infectious material will spill into eases. The condition is usually corrected by a high-
the peritoneal cavity and cause peritonitis, a seri- fiber diet, adequate fluids, and exercise. Although
ous condition. Appendicitis is treated by an appen- laxatives are sometimes used to stimulate defeca-
dectomy (surgical removal of the appendix). tion, frequent laxative use may be habit forming
and lead to chronic constipation.
Cholecystitis
Cholecystitis is an inflammation of the gallblad-
Diarrhea
der. When gallstones form from crystallized cho- Diarrhea is a condition characterized by frequent
lesterol, bile salts, and bile pigments, the watery stools. Causes include infection, stress,
condition is known as cholelithiasis. Symptoms diet, an irritated colon, and toxic substances.
frequently occur after eating fatty foods and Diarrhea can be extremely dangerous in infants
include indigestion, nausea and vomiting, and and small children because of the excessive fluid
loss. Treatment is directed toward eliminating the taminated by the feces of an infected person. It is
cause, providing adequate fluid intake, and mod- the most benign form of hepatitis and is usually
ifying the diet. self-limiting. A vaccine is available to prevent
hepatitis A. Type B, HBV, or serum hepatitis, is
transmitted by body fluids including blood,
Diverticulitis serum, saliva, urine, semen, vaginal secretions,
Diverticulitis is an inflammation of the diverticula, and breast milk. It is more serious than type A
pouches (or sacs) that form in the intestine as the and can lead to chronic hepatitis or to cirrhosis of
mucosal lining pushes through the surrounding the liver. A vaccine developed to prevent hepati-
muscle. When fecal material and bacteria become tis B is recommended for all health care workers.
trapped in the diverticula, inflammation occurs. Type C, or HCV, is also spread through contact
This can result in an abscess or rupture, leading to with blood or body fluids. The main methods of
peritonitis. Symptoms vary depending on the transmission include sharing needles while
amount of inflammation but may include abdom- injecting drugs, getting stuck with a contami-
inal pain, irregular bowel movements, flatus (gas), nated needle or sharps while on the job, or pass-
constipation or diarrhea, abdominal distention ing the virus from an infected mother to the infant
(swelling), low-grade fever, and nausea and vomit- during birth. Hepatitis C is much more likely to
ing. Treatment methods include antibiotics, stool- progress to chronic hepatitis, cirrhosis, or both.
softening medications, pain medications, high- There is no vaccine for type C. Other strains of the
fiber diet, and in severe cases, surgery to remove hepatitis virus that have been identified include
the affected section of colon. types D and E. Symptoms include fever, anorexia
(lack of appetite), nausea, vomiting, fatigue, dark-
colored urine, clay-colored stool, myalgia (mus-
Gastroenteritis cle pain), enlarged liver, and jaundice. Treatment
methods include rest and a diet high in protein
Gastroenteritis is an inflammation of the mucous
and calories and low in fat. A liver transplant may
membrane that lines the stomach and intestinal
be necessary if the liver is severely damaged.
tract. Causes include food poisoning, infection, and
toxins. Symptoms include abdominal cramping,
nausea, vomiting, fever, and diarrhea. Usual treat-
ment methods are rest and increased fluid intake.
Hernia
In severe cases, antibiotics, intravenous fluids, and A hernia, or rupture, occurs when an internal
medications to slow peristalsis may be used. organ pushes through a weakened area or natural
opening in a body wall. A hiatal hernia is when
the stomach protrudes through the diaphragm
Hemorrhoids and into the chest cavity through the opening for
Hemorrhoids are painful dilated or varicose veins the esophagus (figure 7-60). Symptoms include
of the rectum and/or anus. They may be caused heartburn, stomach distention, chest pain, and
by straining to defecate, constipation, pressure difficult swallowing. Treatment methods include
during pregnancy, insufficient fluid intake, laxa- a bland diet, small frequent meals, staying upright
tive abuse, and prolonged sitting or standing. after eating, and surgical repair. An inguinal her-
Symptoms include pain, itching, and bleeding. nia is when a section of the small intestine pro-
Treatment methods include a high-fiber diet; trudes through the inguinal rings of the lower
increased fluid intake; stool softeners; sitz baths abdominal wall. If the hernia cannot be reduced
or warm, moist compresses; and in some cases, a (pushed back in place), a herniorrhaphy (surgical
hemorrhoidectomy (surgical removal of the hem- repair) is performed.
orrhoids).
Pancreatitis
Hepatitis Pancreatitis is an inflammation of the pancreas.
Hepatitis is a viral inflammation of the liver. Type The pancreatic enzymes begin to digest the pan-
A, HAV or infectious hepatitis, is highly conta- creas itself, and the pancreas becomes necrotic,
gious and is transmitted in food or water con- inflamed, and edematous. If the damage extends
210 CHAPTER 7
Esophagus This part of the

stomach is normally
Ulcer
located below the An ulcer is an open sore on the lining of the diges-
diaphragm.
Cardiac tive tract. Peptic ulcers include gastric (stomach)
sphincter ulcers and duodenal ulcers. The major cause is a
bacterium, Helicobacter pylori (H. pylori), that
burrows into the stomach membranes, allowing
Diaphragm
stomach acids and digestive juices to create an
ulcer. Symptoms include burning pain, indiges-
Stomach
tion, hematemesis (bloody vomitus), and melena
(dark, tarry stool). Usual treatment methods are
antacids, a bland diet, decreased stress, and
Pyloric avoidance of irritants such as alcohol, fried foods,
sphincter tobacco, and caffeine. If the H. pylori bacteria are
present, treatment with antibiotics and a bismuth
preparation, such as Pepto-Bismol, usually cures
the condition. In severe cases, surgery is per-
formed to remove the affected area.
FIGURE 7-60 A hiatal hernia occurs when the Ulcerative Colitis

stomach protrudes through the diaphragm.
Ulcerative colitis is a severe inflammation of the
colon accompanied by the formation of ulcers
and abscesses. It is thought to be caused by stress,
food allergy, or an autoimmune reaction. The
main symptom is diarrhea containing blood, pus,
to blood vessels in the pancreas, hemorrhage and and mucus. Other symptoms include weight loss,
shock occur. Pancreatitis may be caused by exces- weakness, abdominal pain, anemia, and anorexia.
sive alcohol consumption or blockage of pancre- Periods of remission and exacerbation are com-
atic ducts by gallstones. Many cases are idiopathic, mon. Treatment is directed toward controlling
or of unknown cause. Symptoms include severe inflammation, reducing stress with mild seda-
abdominal pain that radiates to the back, nausea, tion, maintaining proper nutrition, and avoiding
vomiting, diaphoresis (excessive perspiration), substances that aggravate the condition. In some
and jaundice if swelling blocks the common bile cases, surgical removal of the affected colon and
duct. Treatment depends on the cause. A chole- creation of a colostomy (an artificial opening in
cystectomy, removal of the gall bladder, is per- the colon that allows fecal material to be excreted
formed if gallstones are the cause. Analgesics for through the abdominal wall) is necessary.
pain and nutritional support are used if the cause
of pancreatitis is alcoholism or idiopathic. This STUDENT: Go to the workbook and complete
type of pancreatitis has a poor prognosis and the assignment sheet for 7:11, Digestive System.
often results in death.
Peritonitis 7:12 Urinary System

Peritonitis, an inflammation of the abdominal
peritoneal cavity, usually occurs when a rupture Objectives
in the intestine allows the intestine contents to After completing this section, you should be able
enter the peritoneal cavity. A ruptured appendix to:
or gallbladder can cause this condition. Symp-
toms include abdominal pain and distention, ♦ Label a diagram of the urinary system
fever, nausea, and vomiting. Treatment methods ♦ Explain the action of the following parts of a
include antibiotics and, if necessary, surgical nephron: glomerulus, Bowman’s capsule, con-
repair of the damaged intestine. voluted tubule, and collecting tubule
♦ State the functions of the ureter, bladder, and ♦ Describe at least three diseases of the urinary
urethra system
♦ Explain why the urethra is different in male ♦ Define, pronounce, and spell all key terms
and female individuals
♦ Interpret at least five terms used to describe
conditions that affect urination
KEY TERMS
bladder hilum urethra (you⬙-wreath⬘-rah)
Bowman’s capsule homeostasis urinary meatus (you⬘-rih-
cortex (core⬘-tex) kidneys nah-ree⬙ me-ate⬘-as)
excretory system (ex⬘-kreh- medulla (meh-due⬘-la) urinary system
tor⬙-ee) nephrons (nef⬘-ronz) urine
glomerulus (glow⬙-mare⬘- renal pelvis void
you-luss) ureters (you⬘-reh⬙-turz)

◆ Dialysis Technician ◆ Medical Laboratory ◆ Nephrologist
Technologist/Technician ◆ Urologist
7:12 INFORMATION Connective tissue helps hold the kidneys in posi-

tion. Each kidney is enclosed in a mass of fatty
The urinary system, also known as the excre- tissue, called an adipose capsule, and covered
tory system, is responsible for removing certain externally by a tough, fibrous tissue, called the
wastes and excess water from the body and for renal fascia, or fibrous capsule.
maintaining the body’s acid–base balance. It is Each kidney is divided into two main sec-
one of the major body systems that maintains tions: the cortex and the medulla. The cortex is
homeostasis, a state of equilibrium or constant the outer section of the kidney. It contains most
state of natural balance in the internal environ- of the nephrons, which aid in the production of
ment of the body. The parts of the urinary system urine. The medulla is the inner section of the
are two kidneys, two ureters, one bladder, and kidney. It contains most of the collecting tubules,
one urethra (figure 7-61). which carry the urine from the nephrons through
The kidneys (figure 7-62) are two bean- the kidney. Each kidney has a hilum, a notched
shaped organs located on either side of the verte- or indented area through which the ureter, nerves,
bral column, behind the upper part of the blood vessels, and lymph vessels enter and leave
abdominal cavity, and separated from this cavity the kidney.
by the peritoneum. Their location is often Nephrons (figure 7-63) are microscopic fil-
described as retroperitoneal. The kidneys are tering units located in the kidneys. There are
protected by the ribs and a heavy cushion of fat. more than one million nephrons per kidney. Each
212 CHAPTER 7
Adrenal Renal cortex

(suprarenal) glands (contains most of
each nephron)
Renal medulla
Renal capsule
Left renal artery
Renal pelvis Left kidney
Inferior vena cava Abdominal aorta
Right and left

ureters
Ureteral orifices
Urinary bladder
(urocyst)
Urethra
External urethral
orifice (urinary
meatus)
FIGURE 7-61 The urinary system.
nephron consists of a glomerulus, a Bowman’s them into the convoluted tubule. As these mate-
capsule, a proximal convoluted tubule, a distal rials pass through the various sections of the
convoluted tubule, and a collecting duct (tubule). tubule, substances needed by the body are reab-
The renal artery carries blood to the kidney. sorbed and returned to the blood capillaries. By
Branches of the renal artery pass through the the time the filtered materials pass through the
medulla to the cortex, where the blood enters the tubule, most of the water, glucose, vitamins, and
first part of the nephron, the glomerulus, which mineral salts have been reabsorbed. Excess glu-
is a cluster of capillaries. As blood passes through cose and mineral salts, some water, and wastes
the glomerulus, water, mineral salts, glucose (including urea, uric acid, and creatinine) remain
(sugar), metabolic products, and other sub- in the tubule and become known as the concen-
stances are filtered out of the blood. Red blood trated liquid called urine. The urine then enters
cells and proteins are not filtered out. The filtered collecting ducts, or tubules, located in the
blood leaves the glomerulus and eventually medulla. These collecting ducts empty into the
makes its way to the renal vein, which carries it renal pelvis (renal basin), a funnel-shaped
away from the kidney. The substances filtered out structure that is the first section of the ureter.
in the glomerulus enter the next section of the The ureters are two muscular tubes approx-
nephron, the Bowman’s capsule. The Bow- imately 10–12 inches in length. One extends from
man’s capsule is a C-shaped structure that sur- the renal pelvis of each kidney to the bladder.
rounds the glomerulus and is the start of the Peristalsis (a rhythmic, wavelike motion of mus-
convoluted tubule. It picks up the materials fil- cle) moves the urine through the ureter from the
tered from the blood in the glomerulus and passes kidney to the bladder.
3.75 cm (1.5 inches) in length that opens in front

of the vagina and carries only urine to the out-
Renal side. In males, the urethra is approximately 20 cm
pyramid (8 inches) in length and passes through the pros-
tate gland and out through the penis. It carries
Renal
both urine (from the urinary system) and semen
papilla
(from the reproductive system), although not at
Hilum the same time.
Urine is the liquid waste product produced
Renal by the urinary system. It is approximately 95 per-
artery cent water. Waste products dissolved in this liq-
uid are urea, uric acid, creatinine, mineral salts,
Renal and various pigments. Excess useful products,
vein such as sugar, can also be found in the urine, but
their presence usually indicates disease. Approxi-
Renal mately 1,500–2,000 milliliters (mL) (1.5–2 quarts)
pelvis of urine are produced daily from the approxi-
mately 150 quarts of liquid that is filtered through
Ureter the kidneys.
Terms used to describe conditions that affect
urination include:
Cortex ♦ Polyuria: excessive urination
♦ Oliguria: below normal amounts of urination
Medulla ♦ Anuria: absence of urination
FIGURE 7-62 A cross section of the kidney. ♦ Hematuria: blood in the urine
♦ Pyuria: pus in the urine
♦ Nocturia: urination at night
The bladder is a hollow, muscular sac that ♦ Dysuria: painful urination
lies behind the symphysis pubis and at the mid-
line of the pelvic cavity. It has a mucous mem-
♦ Retention: inability to empty the bladder
brane lining arranged in a series of folds, called ♦ Incontinence: involuntary urination
rugae. The rugae disappear as the bladder ♦ Proteinuria: protein in the urine
expands to fill with urine. Three layers of visceral
(smooth) muscle form the walls of the bladder,
♦ Albuminuria: albumin (a blood protein) in the
urine
which receives the urine from the ureters and
stores the urine until it is eliminated from the
body. Although the urge to void (urinate, or mic-
turate) occurs when the bladder contains approx-
imately 250 milliliters (mL) (1 cup) of urine, the DISEASES AND
bladder can hold much more. A circular sphinc-
ter muscle controls the opening to the bladder to
ABNORMAL CONDITIONS
prevent emptying. When the bladder is full,
receptors in the bladder wall send out a reflex
Cystitis
action, which opens the muscle. Infants cannot Cystitis is an inflammation of the bladder, usually
control this reflex action. As children age, how- caused by pathogens entering the urinary meatus.
ever, they learn to control the reflex. It is more common in female individuals because
The urethra is the tube that carries the urine of the shortness of the urethra. Symptoms include
from the bladder to the outside. The external frequent urination, dysuria, a burning sensation
opening is called the urinary meatus. The ure- during urination, hematuria, lower back pain,
thra is different in female individuals and male bladder spasm, and fever. Treatment methods are
individual. In females, it is a tube approximately antibiotics and increased fluid intake.
214 CHAPTER 7
Bowman's
(glomerular) capsule
Proximal convoluted tubule
Distal convoluted tubule
Glomerulus
Efferent
arteriole
Cortex
From Medulla
Afferent
kidney
arteriole
artery
Collecting
tubule
Loop of Henle
Capillary net
To kidney vein
Henle's loop
FIGURE 7-63 A nephron unit.
Glomerulonephritis appetite), weight loss, congestive heart failure,

pyuria, and finally, renal failure and death occur.
Glomerulonephritis, or nephritis, is an inflam- Treatment is directed at treating the symptoms,
mation of the glomerulus of the kidney. Acute and treatment methods include a low-sodium
glomerulonephritis usually follows a streptococ- diet, antihypertensive drugs, maintenance of flu-
cal infection such as strep throat, scarlet fever, or ids and electrolytes, and hemodialysis (removal
rheumatic fever. Symptoms include chills, fever, of the waste products from the blood by a hemo-
fatigue, edema, oliguria, hematuria, and albu- dialysis machine) (figure 7-64). When both kid-
minuria (protein in the urine). Treatment meth- neys are severely damaged, a kidney transplant
ods include rest, restriction of salt, maintenance can be performed.
of fluid and electrolyte balance, antipyretics (for
fever), diuretics (for edema), and at times, antibi-
otics. With treatment, kidney function is usually
restored, and the prognosis is good. Repeated
Pyelonephritis
attacks can cause a chronic condition. Chronic Pyelonephritis is an inflammation of the kidney
glomerulonephritis is a progressive disease that tissue and renal pelvis (upper end of the ureter),
causes scarring and sclerosing of the glomeruli. usually caused by pyogenic (pus-forming) bacte-
Early symptoms include hematuria, albuminuria, ria. Symptoms include chills, fever, back pain,
and hypertension. As the disease progresses and fatigue, dysuria, hematuria, and pyuria (pus in
additional glomeruli are destroyed, edema, the urine). Treatment methods are antibiotics
fatigue, anemia, hypertension, anorexia (loss of and increased fluid intake.
Renal Failure
Renal failure is when the kidneys stop function-
ing. Acute renal failure (ARF) can be caused by
hemorrhage, shock, injury, poisoning, nephritis,
or dehydration. Symptoms include oliguria or
anuria, headache, an ammonia odor to the
breath, edema, cardiac arrhythmia, and uremia.
Prompt treatment involving dialysis, restricted
fluid intake, and correction of the condition caus-
ing renal failure results in a good prognosis.
Chronic renal failure (CRF) results from the pro-
gressive loss of kidney function. It can be caused
by chronic glomerulonephritis, hypertension,
toxins, and endocrine disease such as diabetes
mellitus. Long-term substance abuse and alco-
holism can also lead to renal failure. Waste prod-
ucts accumulate in the blood and affect many
body systems. Symptoms include nausea, vomit-
ing, diarrhea, weight loss, decreased mental abil-
ity, convulsions, muscle irritability, an ammonia
odor to the breath, uremic frost (deposits of white
crystals on the skin), and in later stages, coma
prior to death. Treatment methods are dialysis,
diet modifications and restrictions, careful skin
and mouth care, and control of fluid intake. A
kidney transplant is the only cure.
FIGURE 7-64 A hemodialysis machine helps

remove waste products from the blood when the
Uremia
kidneys are not functioning correctly. Uremia, also called azotemia, is a toxic condition
that occurs when the kidneys fail and urinary
waste products are present in the bloodstream. It
can result from any condition that affects the
Renal Calculus proper functioning of the kidneys, such as renal
failure, chronic glomerulonephritis, and hypo-
A renal calculus, or urinary calculus, is a kidney tension. Symptoms include headache, dizziness,
stone. A calculus is formed when salts in the urine nausea, vomiting, an ammonia odor to the breath,
precipitate (settle out of solution). Some small oliguria or anuria, mental confusion, convul-
calculi may be eliminated in the urine, but larger sions, coma, and eventually, death. Treatment
stones often become lodged in the renal pelvis or consists of a restricted diet, cardiac medications
ureter. Symptoms include sudden, intense pain to increase blood pressure and cardiac output,
(renal colic); hematuria; nausea and vomiting; a and dialysis until a kidney transplant can be per-
frequent urge to void; and in some cases, urinary formed.
retention. Initial treatment consists of increasing
fluids, providing pain medication, and straining
all urine through gauze or filter paper to deter-
mine whether stones are being eliminated. Extra- Urethritis
corporeal shock-wave lithotripsy is a procedure Urethritis is an inflammation of the urethra, usu-
where high-energy pressure waves are used to ally caused by bacteria (such as gonococcus),
crush the stones so that they can be eliminated viruses, or chemicals (such as bubble bath solu-
through the urine. In some cases, surgery is tions). It is more common in male than female
required to remove the calculi. individuals. Symptoms include frequent and
216 CHAPTER 7
painful urination, redness and itching at the uri-

nary meatus, and a purulent (pus) discharge. 7:13 Endocrine System
Treatment methods include sitz baths or warm,
moist compresses; antibiotics; and/or increased
Objectives
fluid intake. After completing this section, you should be able
to:
STUDENT: Go to the workbook and complete ♦ Label a diagram of the main endocrine
the assignment sheet for 7:12, Urinary System. glands
♦ Describe how hormones influence various
body functions
♦ Describe at least five diseases of the endocrine
glands
KEY TERMS
adrenal glands (ah⬙-dree⬘- pancreas (pan-kree-as) placenta
nal) parathyroid glands testes (tess⬘-tees)
endocrine system (en⬘-doh⬙- pineal body (pin⬘-knee⬙-ahl) thymus
krin) pituitary gland (pih⬙-too⬘-ih- thyroid gland
hormones tar-ee)
ovaries

◆ Endocrinologist ◆ Nuclear Medicine
Technologist
7:13 INFORMATION ♦ Stimulate other endocrine glands
The endocrine system consists of a group of ♦ Regulate growth and development

ductless (without tubes) glands that secrete sub- ♦ Regulate metabolism
stances directly into the bloodstream. These sub- ♦ Maintain fluid and chemical balance
stances are called hormones. The endocrine
system consists of the pituitary gland, thyroid
♦ Control various sex processes
gland, parathyroid gland, adrenal glands, pan- Table 7-3 lists the main hormones produced
creas, ovaries, testes, thymus, pineal body, and by each endocrine gland and the actions they
placenta (figure 7-65). perform.
Hormones, chemical substances produced
and secreted by the endocrine glands, are fre-
quently called “chemical messengers.” They are
transported throughout the body by the blood- PITUITARY GLAND
stream and perform many functions including: The pituitary gland is often called the “master
♦ Stimulate exocrine glands (glands with ducts, gland” of the body because it produces many
or tubes) to produce secretions hormones that affect other glands. It is located at
Pineal
Pituitary
Thyroid
Thymus
Parathyroid
glands
Posterior view
Cortex Pancreas
(Islets of Langerhans)
Medulla
Adrenal
Testis Ovary
FIGURE 7-65 The endocrine system.
TABLE 7-3 Hormones Produced by the Endocrine Glands and Their Actions
GLAND HORMONE ACTION
Pituitary
Anterior lobe ACTH—adrenocorticotropic Stimulates growth and secretion of the cortex of the adrenal gland
TSH—thyrotropin Stimulates growth and secretion of the thyroid gland
GH—somatotropin Growth hormone, stimulates normal body growth
FSH—follicle stimulating Stimulates growth and hormone production in the ovarian follicles
of female individuals, production of sperm in male individuals
LH—luteinizing (female) Causes ovulation and secretion of progesterone in female individuals
or
ICSH—interstitial cell Stimulates testes to secrete testosterone
stimulating (male)
LTH—lactogenic or prolactin Stimulates secretion of milk from mammary glands after delivery
of an infant
MSH—melanocyte stimulating Stimulates production and dispersion of melanin pigment in the
skin
(continues)
218 CHAPTER 7
TABLE 7-3 Hormones Produced by the Endocrine Glands and Their Actions (Continued)
Posterior lobe ADH—vasopressin Antidiuretic hormone, promotes reabsorption of water in kidneys,

constricts blood vessels
Oxytocin (pitocin) Causes contraction of uterus during childbirth, stimulates milk flow
from the breasts
Thyroid
Thyroxine and tri-iodothyronine Increase metabolic rate; stimulate physical and mental growth;
regulate metabolism of carbohydrates, fats, and proteins
Thyrocalcitonin (calcitonin) Accelerates absorption of calcium by the bones and lowers blood
calcium level
Parathyroid
Parathormone (PTH) Regulates amount of calcium and phosphate in the blood,
increases reabsorption of calcium and phosphates from bones,
stimulates kidneys to conserve blood calcium, stimulates
absorption of calcium in the intestine
Adrenal
Cortex Mineralocorticoids Regulate the reabsorption of sodium in the kidney and the elimina-
Aldosterone tion of potassium, increase the reabsorption of water by the
kidneys
Glucocorticoids Aid in metabolism of proteins, fats, and carbohydrates; increase
Cortisol-hydrocortisone amount of glucose in blood; provide resistance to stress; and
Cortisone depress immune responses (anti-inflammatory)
Gonadocorticoids Act as sex hormones
Estrogens Stimulate female sexual characteristics
Androgens Stimulate male sexual characteristics
Medulla Epinephrine (adrenaline) Activates sympathetic nervous system, acts in times of stress to
increase cardiac output and increase blood pressure
Norepinephrine Activates body in stress situations
Pancreas
Insulin Used in metabolism of glucose (sugar) by promoting entry of
glucose into cells to decrease blood glucose levels, promotes
transport of fatty acids and amino acids (proteins) into the cells
Glucagon Maintains blood level of glucose by stimulating the liver to release
stored glycogen in the form of glucose
Ovaries
Estrogen Promotes growth and development of sex organs in female
individuals
Progesterone Maintains lining of uterus
Testes
Testosterone Stimulates growth and development of sex organs in male
individuals, stimulates maturation of sperm
Thymus
Thymosin (thymopoietin) Stimulates production of lymphocytes and antibodies in early life
(continues)
TABLE 7-3 Hormones Produced by the Endocrine Glands and Their Actions (Continued)
Pineal
Melatonin May delay puberty by inhibiting gonadotropic (sex) hormones, may
regulate sleep/wake cycles
Adrenoglomerulotropin May stimulate adrenal cortex to secrete aldosterone
Serotonin May prevent vasoconstriction of blood vessels in the brain, inhibits
gastric secretions
Placenta
Estrogen Stimulates growth of reproductive organs
Chorionic gonadotropin Causes corpus luteum of ovary to continue secretions
Progesterone Maintains lining of uterus to provide fetal nutrition
the base of the brain in the sella turcica, a small,

bony depression of the sphenoid bone. It is
divided into two sections, or lobes: the anterior
lobe and the posterior lobe. Each lobe secretes
certain hormones, as shown in table 7-3.
Diseases and
Abnormal Conditions
Acromegaly
Acromegaly results from an oversecretion of
somatotropin (growth hormone) in an adult and
is usually caused by a benign (noncancerous)
tumor of the pituitary called an adenoma. Bones
of the hands, feet, and face enlarge and create a
grotesque appearance. The skin and tongue
thicken, and slurred speech develops. Surgical
removal and/or radiation of the tumor is the FIGURE 7-66 Giantism results when the pituitary
usual treatment, but the tumor frequently recurs. gland secretes excessive amounts of somatotropin
Acromegaly eventually causes cardiovascular and (growth hormone) before puberty.
respiratory diseases that shorten life expectancy.
include polyuria (excessive urination), polydipsia
Giantism (excessive thirst), dehydration, weakness, consti-
Giantism results from an oversecretion of somato- pation, and dry skin. The condition is corrected
tropin before puberty (figure 7-66). It causes by administering ADH.
excessive growth of long bones, extreme tallness,
decreased sexual development, and at times, Dwarfism
retarded mental development. If a tumor of the Dwarfism results from an undersecretion of
pituitary is the cause, surgical removal or radia- somatotropin and can be caused by a tumor,
tion is the treatment. infection, genetic factors, or injury (figure 7-67).
It is characterized by small body size, short
Diabetes Insipidus extremities, and lack of sexual development.
Diabetes insipidus is caused by decreased secre- Mental development is usually normal. If the
tion of vasopressin, or antidiuretic hormone condition is diagnosed early, it can be treated
(ADH). A low level of ADH prevents water from with injections of somatotropic hormone for 5 or
being reabsorbed in the kidneys. Symptoms more years until long bone growth is complete.
220 CHAPTER 7
polydipsia (excessive thirst), goiter formation, and

hypertension. An excessive appetite with extreme
weight loss is a classic symptom. Treatment con-
sists of either radiation to destroy part of the thy-
roid or a thyroidectomy (surgical removal of the
thyroid). If the thyroid is removed, thyroid hor-
mones are given for the lifetime of the individual.
Graves’ Disease
Graves’ disease is a severe form of hyperthyroid-
ism more common in women than men.
Symptoms include a strained and tense facial
FIGURE 7-67 Dwarfism results from an underse- expression, exophthalmia (protruding eyeballs),
cretion of somatotropin (growth hormone). goiter, nervous irritability, emotional instability,
tachycardia, a tremendous appetite accompa-
nied by weight loss, and diarrhea. Treatment
THYROID GLAND methods include medication to inhibit the syn-
thesis of thyroxine, radioactive iodine to destroy
The thyroid gland synthesizes hormones that thyroid tissue, and/or a thyroidectomy.
regulate the body’s metabolism and control the
level of calcium in the blood. It is located in front Hypothyroidism
of the upper part of the trachea (windpipe) in the Hypothyroidism is an underactivity of the thyroid
neck. It has two lobes, one on either side of the gland and a deficiency of thyroid hormones. Two
larynx (voice box), connected by the isthmus, a main forms exist: cretinism and myxedema. Cre-
small piece of tissue. To produce its hormones, tinism develops in infancy or early childhood and
the thyroid gland requires iodine, which is results in a lack of mental and physical growth,
obtained from certain foods and iodized salt. The leading to mental retardation and an abnormal,
hormones secreted by the thyroid gland are dwarfed stature. If diagnosed early, oral thyroid
shown in table 7-3. hormone can be given to minimize mental and
physical damage. Myxedema occurs in later child-
hood or adulthood. Symptoms include coarse, dry
Diseases and skin; slow mental function; fatigue; weakness;
intolerance of cold; weight gain; edema; puffy
Abnormal Conditions eyes; and a slow pulse. Treatment consists of
Goiter administering oral thyroid hormone to restore
A goiter is an enlargement of the thyroid gland. normal metabolism. In some countries where
Causes can include a hyperactive thyroid, an iodized salt is not available, myxedema may be
iodine deficiency, an oversecretion of thyroid- caused by an iodine deficiency. Adding iodine to
stimulating hormone on the part of the pituitary the diet corrects this type of myxedema.
gland, or a tumor. Symptoms include thyroid
enlargement, dysphagia (difficult swallowing), a
cough, and a choking sensation. Treatment is
directed toward eliminating the cause. For exam-
PARATHYROID GLANDS
ple, iodine is given if a deficiency exists. Surgery The parathyroid glands are four small glands
may be performed to remove very large goiters. located behind and attached to the thyroid gland.
Their hormone, parathormone, regulates the
Hyperthyroidism amount of calcium in the blood (see table 7-3). It
Hyperthyroidism is an overactivity of the thyroid stimulates bone cells to break down bone tissue
gland, which causes increased production of thy- and release calcium and phosphates into the
roid hormones and increased basal metabolic rate blood, causes the kidneys to conserve and reab-
(BMR). Symptoms include extreme nervousness, sorb calcium, and activates intestinal cells to
tremors, irritability, rapid pulse, diarrhea, diapho- absorb calcium from digested foods. Although
resis (excessive perspiration), heat intolerance, most of the body’s calcium is in the bones, the
calcium circulating in the blood is important for groups: mineralocorticoids, glucocorticoids, and
blood clotting, the tone of heart muscle, and gonadocorticoids. The groups and the main hor-
muscle contraction. Because there is a constant mones in each group are listed in table 7-3. The
exchange of calcium and phosphate between the adrenal medulla secretes two main hormones:
bones and blood, the parathyroid hormone plays epinephrine and norepinephrine. These hor-
an important function in maintaining the proper mones are sympathomimetic; that is, they mimic
level of circulating calcium. the sympathetic nervous system and cause the
fight or flight response.
Diseases and Abnormal

Diseases and Abnormal
Conditions
Hyperparathyroidism
Conditions
Hyperparathyroidism is an overactivity of the Addison’s Disease
parathyroid gland resulting in an overproduc- Addison’s disease is caused by decreased secre-
tion of parathormone. This results in hypercalce- tion of aldosterone on the part of the adrenal cor-
mia (increased calcium in the blood), which leads tex. This interferes with the reabsorption of
to renal calculi (kidney stones) formation, leth- sodium and water and causes an increased level
argy, gastrointestinal disturbances, and calcium of potassium in the blood. Symptoms include
deposits on the walls of blood vessels and organs. dehydration, diarrhea, fatigue, hypotension (low
Because the calcium is drawn from the bones, blood pressure), mental lethargy, weight loss,
they become weak, deformed, and likely to frac- muscle weakness, excessive pigmentation lead-
ture. This condition is often caused by an ade- ing to a “bronzing” (yellow-brown color) of the
noma (glandular tumor), and removal of the skin, hypoglycemia (low blood sugar), and edema.
tumor usually results in normal parathyroid func- Treatment methods include administering corti-
tion. Other treatments include surgical removal costeroid hormones, controlled intake of sodium,
of the parathyroids followed by administration of and fluid regulation to combat dehydration.
parathormone, diuretics to increase the excretion
of water and calcium, and a low-calcium diet. Cushing’s Syndrome
Cushing’s syndrome results from an oversecre-
Hypoparathyroidism tion of glucocorticoids on the part of the adrenal
Hypoparathyroidism is an underactivity of the cortex. It can be caused by either a tumor of the
parathyroid gland, which causes a low level of adrenal cortex or excess production of ACTH on
calcium in the blood. Causes include the surgical the part of the pituitary gland. Symptoms include
removal of or injury to the parathyroid and/or hyperglycemia (high blood sugar), hypertension,
thyroid glands. Symptoms include tetany (a sus- muscle weakness, fatigue, hirsutism (excessive
tained muscular contraction), hyperirritability of growth and/or an abnormal distribution of hair),
the nervous system, and convulsive twitching. poor wound healing, a tendency to bruise easily,
Death can occur if the larynx and respiratory a “moon” face, and obesity (figure 7-68). If a tumor
muscles are involved. The condition is easily is causing the disease, treatment is removal of the
treated with calcium, vitamin D (which increases tumor. If the glands are removed, hormonal ther-
the absorption of calcium from the digestive apy is required to replace the missing hormones.
tract), and parathormone. Cushing’s syndrome can also occur in patients
receiving long-term steroid therapy such as pred-
nisone. These patients must be monitored closely,
and steroid therapy must be reduced gradually if
ADRENAL GLANDS symptoms of Cushing’s syndrome develop.
The adrenal glands are frequently called the
suprarenal glands because one is located above
each kidney. Each gland has two parts: the outer
PANCREAS
portion, or cortex, and the inner portion, or The pancreas is a fish-shaped organ located
medulla. The adrenal cortex secretes many ste- behind the stomach. It is both an exocrine gland
roid hormones, which are classified into three and an endocrine gland. As an exocrine gland, it
222 CHAPTER 7
FIGURE 7-68 Cushing’s syndrome. (A) The classic “moon face” of Cushing’s syndrome. (B) The same
individual after treatment. (Courtesy of Ruth Jones)
secretes pancreatic juices, which are carried to controlled with diet and/or oral hypoglycemic
the small intestine by the pancreatic duct to aid (lower-blood-sugar) medications. The main
in the digestion of food. Special B, or beta, cells symptoms include hyperglycemia (high blood
located throughout the pancreas in patches of sugar), polyuria (excessive urination), polydipsia
tissue called islets of Langerhans produce the (excessive thirst), polyphagia (excessive hunger),
hormone insulin, which is needed for the cells to glycosuria (sugar in the urine), weight loss,
absorb sugar from the blood. Insulin also pro- fatigue, slow healing of skin infections, and vision
motes the transport of fatty acids and amino changes. If the condition is not treated, diabetic
acids (proteins) into the cells. Alpha, or A, cells coma and death may occur. Treatment methods
produce the hormone glucagon, which increases are a carefully regulated diet to control the blood
the glucose level in blood (see table 7-3). sugar level, regulated exercise, and oral hypogly-
cemic drugs or insulin injections. Newer medica-
tions that increase insulin production, increase
Disease the sensitivity to insulin, or slow the absorption
Diabetes Mellitus of glucose into cells are also available. External
Diabetes mellitus is a chronic disease caused by and implantable insulin pumps that monitor
decreased secretion of insulin. The metabolism blood glucose levels and deliver the required
of carbohydrates, proteins, and fats is affected. amount of insulin can be used to replace insulin
There are two main types of diabetes mellitus, injections. A new form of therapy is an inhaled
named according to the age of onset and need for form of insulin. However, this is expensive and
insulin. Insulin-dependent diabetes mellitus has not been approved for use in children.
(IDDM), or Type 1, usually occurs early in life, is Estimates indicate that more than 16 million
more severe, and requires insulin. Noninsulin- Americans have diabetes, and as many as 40–50
dependent diabetes mellitus (NIDDM), or Type 2, percent might not know they have the disease.
is the mature-onset form of diabetes mellitus. It Researchers have proved that weight control
frequently occurs in obese adults and is usually (avoiding obesity) and moderate exercise can
reduce the risk for development of diabetes by as The thymus is a mass of tissue located in the
much as 55–70 percent. Preventing diabetes is upper part of the chest and under the sternum. It
important because diabetes can cause athero- contains lymphoid tissue. The thymus is active in
sclerosis, myocardial infarctions (heart attacks), early life, activating cells in the immune system,
cerebrovascular accidents (strokes), peripheral but atrophies (wastes away) during puberty,
vascular disease leading to poor wound healing when it becomes a small mass of connective tis-
and gangrene in the legs and feet, diabetic reti- sue and fat. It produces one hormone, thymosin
nopathy causing blindness, and kidney disease (see table 7-3).
or failure. The pineal body is a small structure attached
to the roof of the third ventricle in the brain.
Knowledge regarding the physiology of this gland
OTHER ENDOCRINE is limited. Three main hormones secreted by this
GLANDS gland are listed in table 7-3.
The placenta is a temporary endocrine
The ovaries are the gonads, or sex glands, of the gland produced during pregnancy. It acts as a link
female. They are located in the pelvic cavity, one between the mother and infant, provides nutri-
on each side of the uterus. They secrete hormones tion for the developing infant, and promotes lac-
that regulate menstruation and secondary sexual tation (the production of milk in the breasts). It is
characteristics (see table 7-3). expelled after the birth of the child (when it is
The testes are the gonads of the male. They called afterbirth). Three hormones secreted by
are located in the scrotal sac and are suspended this gland are listed in table 7-3.
outside the body. They produce hormones that
regulate sexual characteristics of the male (see STUDENT: Go to the workbook and complete
table 7-3). the assignment sheet for 7:13, Endocrine System.
7:14 Reproductive System ♦ Identify at least three organs of the male repro-
ductive system that secrete fluids added to
Objectives semen
After completing this section, you should be able ♦ Label a diagram of the female reproductive
to: system
♦ Label a diagram of the male reproductive sys- ♦ Describe how an ovum is released from an
tem ovary
♦ Trace the pathway of sperm from where they ♦ Explain the action of the endometrium
are produced to where they are expelled from ♦ Describe at least six diseases of the reproduc-
the body tive systems
KEY TERMS
Bartholin’s glands (Bar⬘-tha- epididymis (eh⬙-pih-did⬘-ih- labia minora (lay⬘-bee⬙-ah
lens) muss) ma-nore⬘-ah)
breasts fallopian tubes (fah-low⬘- ovaries
Cowper’s (bulbourethral) pea⬙-an) penis
glands (Cow⬘-purrs) fertilization (fur⬙-til-ih-zay⬘- perineum (pear⬙-ih-knee⬘-
ejaculatory ducts (ee-jack⬘- shun) um)
you-lah-tore⬙-ee) labia majora (lay⬘-bee⬙-ah prostate gland
endometrium (en⬙-doe-me⬘- mah⬙-jore⬘-ah) reproductive system
tree-um) scrotum (skrow⬘-tum)
224 CHAPTER 7
KEY TERMS
seminal vesicles (sem⬘-ih- uterus vestibule
null ves⬘-ik-ullz) vagina (vah-jie⬘-nah) vulva (vull⬘-vah)
testes (tes⬘-tees) vas (ductus) deferens (vass
urethra deaf⬘-eh-rens)

◆ Embryologist ◆ Gynecologist ◆ Ultrasound Technologist
◆ Genetic Counselor ◆ Midwife
(Sonographer)
◆ Geneticist ◆ Obstetrician
7:14 INFORMATION After the sperm develop in the seminiferous

tubules in the testes, they enter the epididymis.
The function of the reproductive system is to The epididymis is a tightly coiled tube approxi-
produce new life. Although the anatomic parts mately 20 feet in length and located in the scro-
differ in male and female individuals, the repro- tum and above the testes. It stores the sperm
ductive systems of both have the same types of while they mature and become motile (able to
organs: gonads (sex glands); ducts (tubes) to carry move by themselves). It also produces a fluid that
the sex cells and secretions; and accessory becomes part of the semen (fluid released during
organs. ejaculation). The epididymis connects with the
next tube, the vas deferens.
The vas (ductus) deferens receives the
MALE REPRODUCTIVE sperm and fluid from the epididymis. On each
side, a vas deferens joins with the epididymis and
SYSTEM extends up into the abdominal cavity, where it
curves behind the urinary bladder and joins with
The male reproductive system consists of the tes- a seminal vesicle. Each vas deferens acts as both
tes, epididymis, vas deferens, seminal vesicles, a passageway and a temporary storage area for
ejaculatory ducts, urethra, prostate gland, Cowp- sperm. The vas deferens are also the tubes that
er’s glands, and penis (figure 7-69). are cut during a vasectomy (procedure to produce
The male gonads are the testes. The two tes- sterility in the male).
tes are located in the scrotum, a sac suspended The seminal vesicles are two small pouch-
between the thighs. The testes produce the male like tubes located behind the bladder and near
sex cells called sperm, or spermatozoa, in semi- the junction of the vas deferens and the ejacula-
niferous tubules located within each testis. tory ducts. They contain a glandular lining. This
Because the scrotum is located outside the body, lining produces a thick, yellow fluid that is rich in
the temperature in the scrotum is lower than that sugar and other substances and provides nour-
inside the body. This lower temperature is essen- ishment for the sperm. This fluid composes a
tial for the production of sperm. The testes also large part of the semen.
produce male hormones. The main hormone is The ejaculatory ducts are two short tubes
testosterone, which aids in the maturation of the formed by the union of the vas deferens and the
sperm and also is responsible for the secondary seminal vesicles. They carry the sperm and fluids
male sex characteristics such as body hair, facial known collectively as semen through the prostate
hair, large muscles, and a deep voice. gland and into the urethra.
Ureter
Rectum
Urinary
bladder Seminal
vesicle
Pubis
Ejaculatory duct
Ductus
deferens Prostate gland
Penis
Urinary bladder
Anus
Ureter
Glans
penis Seminal
Bulbourethral
vesicle
gland
Testis Urethra
Epididymis
Scrotum Ejaculatory
Prostate gland duct
(A)
Ductus deferens
Penis
Bulbourethral
gland
Epididymis
Urethra
Testis
(B)
FIGURE 7-69 The male reproductive system. (A) Lateral view. (B) Anterior view.
The prostate gland is a doughnut-shaped nected by small tubes to the urethra. They secrete
gland located below the urinary bladder and on mucus, which serves as a lubricant for inter-
either side of the urethra. It produces an alkaline course, and an alkaline fluid, which decreases the
secretion that both increases sperm motility and acidity of the urine residue in the urethra, provid-
neutralizes the acidity in the vagina, providing a ing a more favorable environment for the sperm.
more favorable environment for the sperm. The The urethra is the tube that extends from
muscular tissue in the prostate contracts during the urinary bladder, through the penis, and to the
ejaculation (expulsion of the semen from the outside of the body. It carries urine from the uri-
body) to aid in the expulsion of the semen into nary bladder and semen from the reproductive
the urethra. When the prostate contracts, it also tubes.
closes off the urethra, preventing urine passage The penis is the external male reproductive
through the urethra. organ and is located in front of the scrotum. At
Cowper’s (bulbourethral) glands are two the distal end is an enlarged structure, called the
small glands located below the prostate and con- glans penis. The glans penis is covered with a pre-
226 CHAPTER 7
puce (foreskin), which is sometimes removed retention, a prostatectomy (surgical removal of

surgically in a procedure called circumcision. The all or part of the prostate) is necessary. A trans-
penis is made of spongy, erectile tissue. During urethral resection (TUR), or removal of part of
sexual arousal, the spaces in this tissue fill with the prostate, is performed by inserting a scope
blood, causing the penis to become erect. The into the urethra and resecting, or removing, the
penis functions as the male organ of copulation, enlarged area. A prostatectomy can also be done
or intercourse; deposits the semen in the vagina; by a perineal, or suprapubic (above the pubis
and provides for the elimination of urine from bone), incision. Prostatic carcinoma (cancer) can
the bladder through the urethra. have the same symptoms as prostatic hypertro-
phy or it may not have any symptoms. A screen-
ing blood test, called a prostatic-specific antigen
Diseases and (PSA) test, can detect a substance released by
cancer cells and aid in an early diagnosis. A digi-
Abnormal Conditions tal rectal examination may show a hard, abnor-
Epididymitis mal mass in the prostate gland. A tissue biopsy of
Epididymitis is an inflammation of the epididy- the prostate is usually performed to diagnose
mis, usually caused by a pathogenic organism cancer.
such as gonococcus, streptococcus, or staphylo- If the condition is malignant, prostatectomy,
coccus. It frequently occurs with a urinary tract radiation, and estrogen therapy (to decrease the
or prostate infection, mumps, or sexually trans- effects of testosterone) are the main treatments.
mitted diseases (STDs). If epididymitis is not In some cases, an orchiectomy, surgical removal
treated promptly, it can cause scarring and steril- of the testes, is performed to stop the production
ity. Symptoms include intense pain in the testes, of testosterone. Radioactive seeds can also be
swelling, and fever. Treatment methods include implanted in the prostate to destroy the cancer-
antibiotics, cold applications, scrotal support, ous cells without affecting the organs and tissue
and pain medication. surrounding the prostate. If prostate cancer is
detected early, the prognosis (expected outcome)
Orchitis is good. All men older than 50 years are encour-
Orchitis is an inflammation of the testes, usually aged to have annual prostate examinations.
caused by mumps, pathogens, or injury. It can
lead to atrophy of the testes and cause sterility. Testicular Cancer
Symptoms include swelling of the scrotum, pain, Testicular cancer, or cancer of the testes, occurs
and fever. Treatment methods include antibiotics most frequently in men from ages 20 to 35. It is a
(if indicated), antipyretics (for fever), scrotal sup- highly malignant form of cancer and can metas-
port, and pain medication. Prevention methods tasize, or spread, rapidly. Symptoms include a
include mumps vaccinations and observing mea- painless swelling of the testes, a heavy feeling,
sures to prevent sexually transmitted diseases and an accumulation of fluid. Treatment includes
(STDs). an orchiectomy, or surgical removal of the testis,
chemotherapy, and/or radiation. It has been rec-
Prostatic Hypertrophy and Cancer ommended that male individuals begin monthly
Prostatic hypertrophy, or hyperplasia, is an testicular self-examinations at the age of 15. To
enlargement of the prostate gland. Common in perform the examination, the male individuals
men over age 50, prostatic hypertrophy can be a should examine the testicles after a warm shower
benign condition, caused by inflammation, a when scrotal skin is relaxed. Each testicle should
tumor, or a change in hormonal activity, or a be examined separately with both hands by plac-
malignant (cancerous) condition. Symptoms of ing the index and middle fingers under the testi-
prostatic hypertrophy include difficulty in start- cle and the thumbs on top. The testicle should be
ing to urinate, frequent urination, nocturia (void- rolled gently between the fingers to feel for lumps,
ing at night), dribbling, urinary infections, and nodules, or extreme tenderness. In addition, the
when the urethra is blocked, urinary retention. male should examine the testes for any signs of
Initial treatment methods include fluid restric- swelling or changes in appearance. If any abnor-
tion, antibiotics (for infections), and prostatic malities are noted, the male should be examined
massage. When hypertrophy causes urinary by a physician as soon as possible.
FEMALE have fingerlike projections, called fimbriae. The

fimbriae help move the ovum, which is released
REPRODUCTIVE SYSTEM by the ovary, into the fallopian tube. Each fallo-
pian tube serves as a passageway for the ovum as
The female reproductive system consists of the the ovum moves from the ovary to the uterus. The
ovaries, fallopian tubes, uterus, vagina, Bartho- muscle layers of the tube move the ovum by peri-
lin’s glands, vulva, and breasts (figure 7-70). stalsis. Cilia, hairlike structures on the lining of
The ovaries are the female gonads (figure the tubes, also keep the ovum moving toward the
7-71). They are small, almond-shaped glands uterus. Fertilization, the union of the ovum and
located in the pelvic cavity and attached to the a sperm to create a new life, usually takes place in
uterus by ligaments. The ovaries contain thou- the fallopian tubes.
sands of small sacs called follicles. Each follicle The uterus is a hollow, muscular, pear-
contains an immature ovum, or female sex cell. shaped organ located behind the urinary bladder
When an ovum matures, the follicle enlarges and and in front of the rectum. It is divided into three
then ruptures to release the mature ovum. This parts: the fundus (the top section, where the fal-
process, called ovulation, usually occurs once lopian tubes attach); the body, or corpus (the
every 28 days. The ovaries also produce hormones middle section); and the cervix (the narrow, bot-
that aid in the development of the reproductive tom section, which attaches to the vagina). The
organs and produce secondary sexual character- uterus is the organ of menstruation, allows for
istics. the development and growth of the fetus, and
The fallopian tubes are two tubes, each contracts to aid in expulsion of the fetus during
approximately 5 inches in length and attached to birth. The uterus has three layers. The inner layer
the upper part of the uterus. The lateral ends of is called the endometrium. This layer of spe-
these tubes are located above the ovaries but are cialized epithelium provides for implantation of
not directly connected to the ovaries. These ends a fertilized ovum and aids in the development of
Suspensory
Uterine ligament
tube
Ovary
Rectouterine
Round pouch
ligament
Uterus
Vesicouterine
pouch Fornix
Urinary Cervix
bladder
Rectum
Symphysis
pubis Vagina
Urethra
Clitoris
Urethral orifice Anus
Labia
minora
Labia Vaginal
majora orifice
FIGURE 7-70 The female reproductive system.
228 CHAPTER 7
Suspensory
ligament
Fundus of Uterine
uterus cavity
Mesovarium Infundibulum
Uterine
Ovary tube
Fimbriae
Ovarian ligament
Round ligament
Broad ligament
Endometrium
Body of Wall of
uterus Myometrium
uterus
Fornix Perimetrium
Cervix of uterus
Internal os
External os
Vagina
FIGURE 7-71 Anterior view of the female reproductive system.
the fetus. If fertilization does not occur, the endo- to the urethra and the vagina. An area of erectile
metrium deteriorates and causes the bleeding tissue, called the clitoris, is located at the junc-
known as menstruation. The middle layer of the tion of the labia minora. It produces sexual
uterus, the myometrium, is a muscle layer. It arousal when stimulated directly or indirectly
allows for the expansion of the uterus during during intercourse. The perineum is defined as
pregnancy and contracts to expel the fetus dur- the area between the vagina and anus in the
ing birth. The outer layer, the perimetrium, is a female body, although it can be used to describe
serous membrane. the entire pelvic floor in both the male and female
The vagina is a muscular tube that connects individual.
the cervix of the uterus to the outside of the body. The breasts, or mammary glands, contain
It serves as a passageway for the menstrual flow, lobes separated into sections by connective and
receives the sperm and semen from the male, is fatty tissue. Milk ducts located in the tissue exit
the female organ of copulation, and acts as the on the surface at the nipples. The main function
birth canal during delivery of the infant. The of the glands is to secrete milk (lactate) after
vagina is lined with a mucous membrane arranged childbirth.
in folds called rugae. The rugae allow the vagina
to enlarge during childbirth and intercourse.
Bartholin’s glands, also called vestibular Diseases and
glands, are two small glands located one on each
side of the vaginal opening. They secrete mucus
Abnormal Conditions
for lubrication during intercourse. Breast Tumors
The vulva is the collective name for the struc- Breast tumors can be benign or malignant. Symp-
tures that form the external female genital area toms include a lump or mass in the breast tissue,
(figure 7-72). The mons veneris, or mons pubis, is a change in breast size or shape (flattening or
the triangular pad of fat that is covered with hair bulging of tissue), and a discharge from the nip-
and lies over the pubic area. The labia majora ple. Breast self-examination (BSE) can often
are the two large folds of fatty tissue that are cov- detect tumors early (figure 7-73). The American
ered with hair on their outer surfaces; they Cancer Society recommends that an adult woman
enclose and protect the vagina. The labia should do a BSE every month at the end of men-
minora are the two smaller hairless folds of tis- struation, or on a scheduled day of the month
sue that are located within the labia majora. The after menopause. The breasts should be exam-
area of the vulva located inside the labia minora ined in front of a mirror to observe for changes in
is called the vestibule. It contains the openings appearance, in a warm shower after soaping the
Labia majora Mons pubis
Clitoris
Urethral meatus
Skene's glands
Labia minora
Vaginal introitus
Hymen
Opening of
Bartholin's gland
Fourchette
Perineum
Anus
FIGURE 7-72 The external female genital area.

breasts, and while lying flat in a supine position. panhysterectomy (surgical removal of the uterus,
A physician should be contacted immediately if ovaries, and fallopian tubes); chemotherapy;
any abnormalities are found. In addition, the and/or radiation.
American Cancer Society recommends that
women between the ages of 35 and 40 years Endometriosis
should have a baseline mammogram. Between Endometriosis is the abnormal growth of endo-
ages 40 and 49, women should have a mammo- metrial tissue outside the uterus. The tissue can
gram every 1–2 years, and after age 50, women be transferred from the uterus by the fallopian
should have a mammogram every year. Mammo- tubes, blood, or lymph, or during surgery. It usu-
grams and ultrasonography can often detect ally becomes embedded in a structure in the pel-
tumors or masses up to 2 years before the tumor vic area, such as the ovaries or the peritoneal
or mass could be felt. Treatment methods for tissues, and constantly grows and sheds. Endo-
breast tumors include a lumpectomy (removal of metriosis can cause sterility if the fallopian tubes
the tumor), a simple mastectomy (surgical become blocked with scar tissue. Symptoms
removal of the breast), or a radical mastectomy include pelvic pain, abnormal bleeding, and dys-
(surgical removal of the tissue, underlying mus- menorrhea (painful menstruation). Treatment
cles, and axillary lymph nodes). If the tumor is methods vary with the age of the patient and the
malignant, chemotherapy and/or radiation are degree of abnormal growth but can include hor-
usually used in addition to surgery. monal therapy, pain medications, and/or surgi-
cal removal of affected organs.
Cervical or Uterine Cancer
Cancer of the cervix and/or uterus is common in Ovarian Cancer
women. Cervical cancer can be detected early by Ovarian cancer is one of the most common causes
a Pap smear. Symptoms of cervical cancer include of cancer deaths in women. It frequently occurs
abnormal vaginal discharge and bleeding. Symp- between ages 40 and 65. Initial symptoms are
toms of uterine cancer include an enlarged vague and include abdominal discomfort and
uterus, a watery discharge, and abnormal bleed- mild gastrointestinal disturbances such as con-
ing. Treatment methods include a hysterectomy stipation and/or diarrhea. As the disease pro-
(surgical removal of the uterus and cervix) or gresses, pain, abdominal distention, and urinary
230 CHAPTER 7
Images not available due to copyright restrictions
frequency occur. Treatment includes surgical ence some degree of PMS. The cause is unknown
removal of all of the reproductive organs and but may be related to a hormonal or biochemical
affected lymph nodes, chemotherapy, and radia- imbalance, poor nutrition, or stress. Symptoms
tion in some cases. vary and may include nervousness, irritability,
depression, headache, edema, backache, consti-
Pelvic Inflammatory Disease pation, abdominal bloating, temporary weight
Pelvic inflammatory disease (PID) is an inflam- gain, and breast tenderness and enlargement.
mation of the cervix (cervicitis) the endometrium Treatment is geared mainly toward relieving
of the uterus (endometritis), fallopian tubes (sal- symptoms, and methods include diet modifica-
pingitis), and at times, the ovaries (oophoritis). It tion, exercise, stress reduction, diuretics to
is usually caused by pathogenic organisms such remove excess fluids, analgesics for pain, and/or
as bacteria, viruses, and fungi. Symptoms include medications to relieve the emotional symptoms.
pain in the lower abdomen, fever, and a purulent
(pus) vaginal discharge. Treatment methods
include antibiotics, increased fluid intake, rest, SEXUALLY
and/or pain medication. TRANSMITTED DISEASES
Premenstrual Syndrome Sexually transmitted diseases (STDs), or sexually
Premenstrual syndrome (PMS) is actually a group transmitted infections (STIs), affect both men and
of symptoms that appear 3–14 days before men- women. The incidence of these diseases has
struation. A large percentage of women experi- increased greatly in recent years, especially
among young people. If not treated, STDs can

cause serious chronic conditions and, in some
cases, sterility or death.
Acquired Immune Deficiency

Syndrome
Acquired immune deficiency syndrome (AIDS) is
caused by a virus called the human immunodefi-
ciency virus (HIV). This virus attacks the body’s
immune system, rendering the immune system
unable to fight off certain infections and diseases,
and eventually causing death. The virus is spread FIGURE 7-74 A common opportunistic disease
through sexual secretions or blood, and from an that occurs in AIDS patients is Kaposi’s sarcoma.
infected mother to her infant during pregnancy (Courtesy of the Centers for Disease Control and
or childbirth. Prevention, Atlanta, GA)
The HIV virus does not live long outside the
body and is not transmitted by casual, nonsexual
cautions should be followed while handling blood,
contact. Individuals infected with HIV can remain
body secretions, and sexual secretions. High-risk
free of any symptoms for years after infection.
sexual activities, such as having multiple partners,
During this asymptomatic period, infected indi-
should be avoided. A condom and an effective
viduals can transmit the virus to any other
spermicide should be used to form a protective
individual with whom they exchange sexual secre-
barrier during intercourse. The use of drugs and
tions, blood, or blood products. After this initial
sharing of intravenous (IV) needles should be
asymptomatic period, many individuals develop
avoided. Females infected with HIV should avoid
HIV symptomatic infection, formerly called
pregnancy. Everyone must concern themselves
AIDS-related complex (ARC). Symptoms include
with eliminating the transmission of AIDS.
a positive blood test for antibodies to the HIV
virus, lack of infection resistance, appetite loss,
weight loss, recurrent fever, night sweats, skin Chlamydia
rashes, diarrhea, fatigue, and swollen lymph
nodes. When the HIV virus causes a critical low Chlamydia (klah-mid-e-ah) is one of the most fre-
level (below 200 cells per cubic millimeter of quently occurring STDs and is caused by several
blood) of special leukocytes (white blood cells) strains of the chlamydia organism, a specialized
called CD4 or T cells, and/or opportunistic dis- bacterium that lives as an intracellular parasite.
eases appear, AIDS is diagnosed. Three of the Symptoms are similar to those of gonorrhea. Male
most common opportunistic diseases include the individuals experience burning when urinating
rare type of pneumonia called Pneumocystis cari- and a mucoid discharge. Female individuals are
nii, a yeast infection called Candidiasis, and the frequently asymptomatic, although some may
slow-growing cancer called Kaposi’s sarcoma (fig- have a vaginal discharge. The disease frequently
ure 7-74). causes pelvic inflammatory disease and sterility
Currently, there is no cure for AIDS, although in women, if not treated. Chlamydia can be treated
much research is being directed toward develop- with tetracycline or erythromycin antibiotics.
ing a vaccine to prevent and drugs to cure AIDS.
Treatment with a combination of drugs, com-
monly called a drug cocktail, is used to slow the Gonorrhea
progression of the disease. These drugs, however, Gonorrhea (gon-oh-re-ah) is caused by the gono-
do not cure the disease. Although several experi- coccus bacterium neisseria gonorrhoeae. Symp-
mental drugs are currently being tested, many toms in male individuals include a greenish-
patients cannot tolerate the side effects and bone yellow discharge, burning when urinating, sore
marrow toxicity of these drugs. Prevention is the throat, and swollen glands. Female individuals
best method in dealing with AIDS. Standard pre- are frequently asymptomatic but may experience
232 CHAPTER 7

Body organs that are grown in the laboratory?
Organ transplants have become a common type of surgery. Hearts, lungs, livers, kidneys,
and many other organs are transplanted daily to save lives. The big problem is the major
shortage of organs to transplant. Today, almost 100,000 Americans are on the national wait-
ing list for an organ. Statistics show that almost 20 percent, or 1 in every 5 patients, will die
before they can receive an organ.
Researchers are trying to grow human organs by using a patient’s own cells. Already,
researchers in Boston have created a urinary bladder that functions in dogs. They molded a
biodegradable material (substance that will dissolve inside the body) in the shape of a blad-
der. They then coated the outside of the structure with layers of muscle cells and the inside
with layers of urothelial cells obtained from a dog’s bladder. After the cells grew and multi-
plied, the dog’s own bladder was removed, and the new artificial organ was transplanted.
Within a month, the organ performed like a normal urinary bladder, storing urine until it
was expelled to the outside. The chance of the dog rejecting the new organ was also slim
because the cells that produced it were the dog’s own cells.
Israeli scientists are using stem cells to grow human kidneys. Stem cells are obtained
from a developing fetus. These cells are capable of transforming themselves into any of the
body’s specialized cells. The scientists transplanted the stem cells into mice and grew human
kidneys in the mice. The kidneys filtered the blood and produced urine. Scientists hope that
the chance of rejection is decreased because the stem cells are immature and less likely to
carry characteristics of a specific individual. Many more trials are needed before these labo-
ratory produced “organs” will be used in humans. However, the future for individuals need-
ing transplants will be much better when scientists can “grow” the organs the individuals
need.
dysuria, pain in the lower abdomen, and Pubic Lice

greenish-yellow vaginal discharge. An infected
woman can transmit the gonococcus organism Pubic lice are parasites that are usually transmit-
to her infant’s eyes during childbirth, causing ted sexually, although they can be spread by con-
blindness. To prevent this, a drop of silver nitrate tact with clothing, bed linen, or other items
or antibiotic is routinely placed in the eyes of containing the lice. Symptoms include an intense
newborn babies. Gonorrhea is treated with large itching and redness of the perineal area. Medica-
doses of antibiotics. tions that kill the lice are used as treatment. To pre-
vent a recurrence, it is essential to wash all clothing
and bed linen to destroy any lice or nits (eggs).
Herpes
Herpes is a viral disease caused by the herpes
simplex virus type II. Symptoms include a burn-
Syphilis
ing sensation, fluid-filled vesicles (blister-like Syphilis is caused by a spirochete bacterium. The
sores) that rupture and form painful ulcers, and symptoms occur in stages. During the primary
painful urination. After the sores heal, the virus stage, a painless chancre (shang-ker), or sore,
becomes dormant. Many people have repeated appears, usually on the penis of the male and in
attacks, but the attacks are milder. There is no the vulva or on the cervix of the female. This
cure, and treatment is directed toward promoting chancre heals within several weeks. During the
healing and easing discomfort. Antiviral medica- second stage, which occurs if the chancre is not
tions are used to decrease the number and sever- treated, the organism enters the bloodstream and
ity of recurrences. causes a rash that does not itch, a sore throat, a
fever, and swollen glands. These symptoms also coordinates the many activities that occur in the
disappear within several weeks. The third stage body and allows the body to respond and adapt
occurs years later after the spirochete has dam- to changes. Special senses provided by organs
aged vital organs. Damage to the heart and blood such as the eyes and ears also allow the body to
vessels causes cardiovascular disease; damage to react to the environment. The respiratory system
the spinal cord causes a characteristic gait and takes in oxygen for use by the body and elimi-
paralysis; and brain damage causes mental disor- nates carbon dioxide, a waste product produced
ders, deafness, and blindness. At this stage, dam- by body cells. The digestive system is responsi-
age is irreversible, and death occurs. Early ble for the physical and chemical breakdown of
diagnosis and treatment with antibiotics can cure food so it can be used by body cells. The urinary
syphilis during the first two stages. system removes certain wastes and excess water
from the body. The endocrine system, composed
of a group of glands, controls many body func-
Trichomoniasis tions. The reproductive system allows the hu-
Trichomoniasis is caused by a parasitic proto- man body to create new life.
zoan, Trichomonas vaginalis. The main symptom All of the systems are interrelated, working as
is a large amount of a frothy, yellow-green, foul- a unit to maintain a constant balance (homeo-
smelling discharge. Men are frequently asymp- stasis) within the human body. When disease oc-
tomatic but may experience urethral itching. The curs, this balance frequently is disturbed. Some
antiparasitic oral medication Flagyl is used to of the major diseases and disorders of each sys-
treat this disease. Both sexual partners must be tem were also discussed in this chapter.
treated to prevent reinfection.

INTERNET SEARCHES
the assignment sheet for 7:14, Reproductive Use the suggested search engines in Chapter 12-4
System. of this textbook to search the Internet for addi-
1. Anatomy and physiology: search the name of a
CHAPTER 7 SUMMARY body system, organ, and/or tissue to obtain

additional information on the structure and
function of the system, organ, or tissue
A health care worker must understand normal 2. Pathophysiology: search the name of specific
functioning of the human body to understand diseases discussed in each subunit to obtain
disease processes. A study of anatomy, the form additional information on occurrence, progno-
and structure of an organism, and physiology, sis, signs and symptoms, and current methods
the processes of living organisms, adds to this of treatment
understanding.
The basic structural unit of the human body 3. American Cancer Society: search this informa-
is the cell. Cells join together to form tissues. Tis- tion base to obtain information on cancer in
sues join together to form organs, which work various parts of the body, breast self-examina-
together to form body systems. tion, testicular self-examination, and statistics
Systems work together to provide for proper on cancer
functioning of the human body. The integumen- 4. Tutorials: search publishers, software provid-
tary system, or skin, provides a protective covers, and bookstore sites to find a variety of
ering for the body. The skeletal and muscular materials that can be used to learn the anat-
systems provide structure and movement. The omy and physiology of the human body
circulatory system transports oxygen and nu-
trients to all body cells and carries carbon di-
oxide and metabolic materials away from the REVIEW QUESTIONS
cells. The lymphatic system assists the circula-
tory system in removing wastes and excess fluid 1. Differentiate between anatomy, physiology,
from the cells and tissues. The nervous system and pathophysiology.
234 CHAPTER 7
2. Name the four (4) main groups of tissues. By vessel or type of vessel, and any organs blood
each tissue, list three (3) body systems that passes through. Make sure all parts are in
contain the tissue. correct order.
3. List at least ten (10) body systems and state the 9. Name all parts of the alimentary canal in
main function(s) of each system. correct order. Begin at the mouth and end at
the anus.
4. Identify the main bones or groups of bones in
both the axial and the appendicular skeleton. 10. Differentiate between endocrine and exocrine
glands. Give five (5) examples of each type of
5. Describe the five (5) main actions or move-
gland and list the main function for each gland.
ments of muscles and provide a specific
example for each type of movement. 11. Evaulate three (3) sexually transmitted diseases
(STDs) and describe how symptoms are the
6. Create a diagram showing the divisions of the
same or different in male versus female indi-
nervous system and list the main parts in each
viduals.
division of the system.
12. Body systems are interrelated and work
7. List four (4) special senses and the organ that is
together to perform specific functions. For
required for each of the senses.
example, the circulatory and respiratory
8. Trace a drop of blood as it enters the heart, systems perform a joint function of obtaining
goes through pulmonary circulation, returns to oxygen for the body and eliminating carbon
the heart, and goes to body cells. Name each dioxide. Describe five (5) other examples of
chamber and valve in the heart, each blood interrelationships between body systems.
CHAPTER 8 Human Growth
and Development
Chapter Objectives
Observe Standard ◆ Identify at least two physical, mental,
Precautions
emotional, and social developments that occur
during each of the seven main life stages
Instructor’s Check—Call ⽧ Explain the causes and treatments for eating
Instructor at This Point disorders and chemical abuse
⽧ Identify methods used to prevent suicide and
Safety—Proceed with list common warning signs
Caution ⽧ Recognize ways that life stages affect an
individual’s needs
OBRA Requirement—Based ⽧ Describe the five stages of grieving that occur
on Federal Law in the dying patient and the role of the health
care worker during each stage
⽧ List two purposes of hospice care and provide
Math Skill
justifications for the “right to die”
⽧ Create examples for each of Maslow’s
Legal Responsibility Hierarchy of Needs
⽧ Name the two main methods people use to
Science Skill meet or satisfy needs
⽧ Describe a situation that shows the use of each
of the following defense mechanisms:
Career Information
rationalization, projection, displacement,
compensation, daydreaming, repression,
Communications Skill suppression, denial, and withdrawal
⽧ Define, pronounce, and spell all key terms
Technology
236 CHAPTER 8
KEY TERMS
acceptance denial physiological needs (fizz⬙-ee-
adolescence depression oh-lodg⬘-ih-kal)
affection development projection
Alzheimer’s disease (Altz⬘- displacement puberty (pew⬘-burr⬙-tee)
high-merz) early adulthood rationalization (rash⬙-en-
anger early childhood nal-ih-zay⬘-shun)
anorexia nervosa (an-oh- emotional repression
rex⬘-see-ah ner-voh⬘-sah) esteem right to die
arteriosclerosis (ar-tear⬙-ee- growth safety
oh-skleh-row⬘-sis) hospice (hoss⬘-pis) satisfaction
bargaining infancy self-actualization
bulimarexia (byou-lee⬙-mah- late adulthood sexuality
rex⬘-ee-ah) social
late childhood
bulimia (byou-lee⬘-me-ah) suicide
life stages
chemical abuse suppression
mental
cognitive tension
middle adulthood
compensation (cahm⬙-pen- terminal illness
motivated
say⬘-shun) withdrawal
needs
daydreaming
physical
defense mechanisms
INTRODUCTION 8:1 INFORMATION

Human growth and development is a process Life Stages
that begins at birth and does not end until death.
Growth refers to the measurable physical Even though individuals differ greatly, each per-
changes that occur throughout a person’s life. son passes through certain stages of growth and
Examples include height, weight, body shape, development from birth to death. These stages
head circumference, physical characteristics, are frequently called life stages. A common
development of sexual organs, and dentition method of classifying life stages is as follows:
(dental structure). Development refers to the
♦ Infancy: birth to 1 year
changes in intellectual, mental, emotional, social,
and functional skills that occur over time. Devel- ♦ Early childhood: 1–6 years
opment is more difficult to measure, but usually ♦ Late childhood: 6–12 years
proceeds from simple to complex tasks as matu- ♦ Adolescence: 12–18 years
ration, or the process of becoming fully grown
and developed, occurs. During all stages of growth ♦ Early adulthood: 19–40 years
and development, individuals have certain tasks ♦ Middle adulthood: 40–65 years
that must be accomplished and needs that must ♦ Late adulthood: 65 years and older
be met. A health care worker must be aware of
the various life stages and of individual needs to As individuals pass through these life stages,
provide quality health care (figure 8-1). four main types of growth and development
Human Growth and Development 237
FIGURE 8-1 An understanding of life stages is important for the health care worker, who may provide care
to individuals of all ages; from the very young (left) to the elderly (right).
occur: physical, mental or cognitive, emotional, to learn and become independent by mastering
and social. Physical refers to body growth and basic tasks, the toddler may develop a sense of
includes height and weight changes, muscle and doubt in his or her abilities. This sense of doubt
nerve development, and changes in body organs. will interfere with later attempts at mastering
Mental or cognitive refers to intellectual devel- independence.
opment and includes learning how to solve prob- Health care providers must understand that
lems, make judgments, and deal with situations. each life stage creates certain needs in individu-
Emotional refers to feelings and includes deal- als. Likewise, other factors can affect life stages
ing with love, hate, joy, fear, excitement, and other and needs. An individual’s sex, race, heredity (fac-
similar feelings. Social refers to interactions and tors inherited from parents, such as hair color
relationships with other people. and body structure) culture, life experiences, and
Each stage of growth and development has its health status can influence needs. Injury or ill-
own characteristics and has specific develop- ness usually has a negative effect and can change
mental tasks that an individual must master. needs or impair development.
These tasks progress from the simple to the more
complex. For example, an individual first learns
to sit, then crawl, then stand, then walk, and then,
finally, run. Each stage establishes the founda-
INFANCY
tion for the next stage. In this way, growth and
development proceeds in an orderly pattern. It is
Physical Development
important to remember, however, that the rate of The most dramatic and rapid changes in growth
progress varies among individuals. Some chil- and development occur during the first year of
dren master speech early, others master it later. life. A newborn baby usually weighs approxi-
Similarly, an individual may experience a sudden mately 6–8 pounds (2.7–3.6 kg) and measures
growth spurt and then maintain the same height 18–22 inches (46–55 cm) (figure 8-2). By the
for a period of time. end of the first year of life, weight has usually
Erik Erikson, a psychoanalyst, has identified tripled, to 21–24 pounds (9.5–11 kg), and height
eight stages of psychosocial development. His has increased to approximately 29–30 inches
eight stages of development, the basic conflict or (74–76 cm).
need that must be resolved at each stage, and Muscular system and nervous system devel-
ways to resolve the conflict are shown in table opments are also dramatic. The muscular and
8-1. Erikson believes that if an individual is not nervous systems are very immature at birth. Cer-
able to resolve a conflict at the appropriate stage, tain reflex actions present at birth allow the infant
the individual will struggle with the same conflict to respond to the environment. These include the
later in life. For example, if a toddler is not allowed Moro, or startle, reflex to a loud noise or sudden
238 CHAPTER 8
TABLE 8-1 Erikson’s Eight Stages of Psychosocial Development

STAGE OF MAJOR
DEVELOPMENT BASIC CONFLICT LIFE EVENT WAYS TO RESOLVE CONFLICT
Infancy Trust versus Mistrust Feeding Infant develops trust in self, others, and the environ-
Birth to 1 Year ment when caregiver is responsive to basic needs
Oral–Sensory and provides comfort; if needs are not met, infant
becomes uncooperative and aggressive, and shows a
decreased interest in the environment
Toddler Autonomy versus Toilet Training Toddler learns control while mastering skills such as
1–3 Years Shame/Doubt feeding, toileting, and dressing when caregivers
Muscular–Anal provide reassurance but avoid overprotection; if
needs are not met, toddler feels ashamed and doubts
own abilities, which leads to lack of self-confidence in
later stages
Preschool Initiative versus Independence Child begins to initiate activities in place of just
3–6 Years Guilt imitating activities; uses imagination to play; learns
Locomotor what is allowed and what is not allowed to develop a
conscience; caregivers must allow child to be
responsible while providing reassurance; if needs are
not met, child feels guilty and thinks everything he or
she does is wrong, which leads to a hesitancy to try
new tasks in later stages
School-Age Industry versus School Child becomes productive by mastering learning and
6–12 Years Inferiority obtaining success; child learns to deal with
Latency academics, group activities, and friends when others
show acceptance of actions and praise success; if
needs are not met, child develops a sense of inferior-
ity and incompetence, which hinders future relation-
ships and the ability to deal with life events
Adolescence Identity versus Peer Adolescent searches for self-identity by making
12–18 Years Role Confusion choices about occupation, sexual orientation, lifestyle,
and adult role; relies on peer group for support and
reassurance to create a self-image separate from
parents; if needs are not met, adolescent experiences
role confusion and loss of self-belief
Young Adulthood Intimacy versus Love Young adult learns to make a personal commitment
19–40 Years Isolation Relationships to others and share life events with others; if self-
identity is lacking, adult may fear relationships and
isolate self from others
Middle Adulthood Generativity Parenting Adult seeks satisfaction and obtains success in life by
40–65 Years versus using career, family, and civic interests to provide
Stagnation for others and the next generation; if adult does not
deal with life issues, feels lack of purpose to life and
sense of failure
Older Adulthood Ego Integrity Reflection on Adult reflects on life in a positive manner, feels
65 Years to Death versus and Acceptance fulfillment with his or her own life and accomplish-
Despair of Life ments, deals with losses, and prepares for death; if
fulfillment is not felt, adult feels despair about life and
fear of death
usually have 10–12 teeth by the end of the first

year of life. At birth, vision is poor and may be
limited to black and white, and eye movements
are not coordinated. By 1 year of age, however,
close vision is good, in color, and can readily
focus on small objects. Sensory abilities such as
those of smell, taste, sensitivity to hot and cold,
and hearing, while good at birth, become more
refined and exact.
Mental Development
Mental development is also rapid during the first
year. Newborns respond to discomforts such as
pain, cold, or hunger by crying. As their needs are
met, they gradually become more aware of their
surroundings and begin to recognize individuals
associated with their care. As infants respond to
stimuli in the environment, learning activities
grow. At birth, they are unable to speak. By 2–4
months, they coo or babble when spoken to, laugh
out loud, and squeal with pleasure. By 6 months
of age, infants understand some words and can
make basic sounds, such as “mama” and “dada.”
FIGURE 8-2 A newborn baby usually weighs By 12 months, infants understand many words
approximately 6–8 pounds and measures 18–22 and use single words in their vocabularies.
inches in length.
movement; the rooting reflex, in which a slight Emotional Development

touch on the cheek causes the mouth to open
and the head to turn; the sucking reflex, caused Emotional development is observed early in life.
by a slight touch on the lips; and the grasp reflex, Newborns show excitement. By 4–6 months of
in which infants can grasp an object placed in the age, distress, delight, anger, disgust, and fear can
hand. Muscle coordination develops in stages. At often be seen. By 12 months of age, elation and
first, infants are able to lift the head slightly. By affection for adults is evident. Events that occur in
2–4 months, they can usually roll from side to the first year of life when these emotions are first
back, support themselves on their forearms when exhibited can have a strong influence on an indi-
prone, and grasp or try to reach objects. By 4–6 vidual’s emotional behavior during adulthood.
months, they can turn the body completely
around, accept objects handed to them, grasp
stationary objects such as a bottle, and with sup-
Social Development
port, hold the head up while sitting. By 6–8 Social development progresses gradually from the
months, infants can sit unsupported, grasp mov- self-centeredness concept of the newborn to the
ing objects, transfer objects from one hand to the recognition of others in the environment. By 4
other, and crawl on the stomach. By 8–10 months, months of age, infants recognize their caregivers,
they can crawl using their knees and hands, pull smile readily, and stare intently at others (figure
themselves to a sitting or standing position, and 8-3). By 6 months of age, infants watch the activi-
use good hand–mouth coordination to put things ties of others, show signs of possessiveness, and
in their mouths. By 12 months, infants frequently may become shy or withdraw when in the pres-
can walk without assistance, grasp objects with ence of strangers. By 12 months of age, infants
the thumb and fingers, and throw small objects. may still be shy with strangers, but they socialize
Other physical developments are also dra- freely with familiar people, and mimic and imitate
matic. Most infants are born without teeth, but gestures, facial expressions, and vocal sounds.
240 CHAPTER 8
FIGURE 8-3 By 4 months of age, infants recog-

nize their caregivers and stare intently at others.
FIGURE 8-4 One to two-year-olds are interested
in many different activities, but they have short
attention spans.
Needs
Infants are dependent on others for all needs. ber details and begin to understand concepts.
Food, cleanliness, and rest are essential for physi- Four-year-olds ask frequent questions and usu-
cal growth. Love and security are essential for ally recognize letters and some words. They begin
emotional and social growth. Stimulation is to make decisions based on logic rather than on
essential for mental growth. trial and error. By age 6, children are very verbal
and want to learn how to read and write. Memory
has developed to the point where the child can
EARLY CHILDHOOD make decisions based on both past and present
experiences.
During early childhood, from 1–6 years of age, Emotional Development
physical growth is slower than during infancy. By Emotional development also advances rapidly. At
age 6, the average weight is 45 pounds (20.4 kg), ages 1–2, children begin to develop self-aware-
and the average height is 46 inches (116 cm). ness and to recognize the effect they have on
Skeletal and muscle development helps the child other people and things. Limits are usually estab-
assume a more adult appearance. The legs and lished for safety, leading the 1- or 2-year-old to
lower body tend to grow more rapidly than do the either accept or defy such limits. By age 2, most
head, arms, and chest. Muscle coordination children begin to gain self-confidence and are
allows the child to run, climb, and move freely. As enthusiastic about learning new things (figure
muscles of the fingers develop, the child learns to 8-5). However, children can feel impatient and
write, draw, and use a fork and knife. By age 2 or frustrated as they try to do things beyond their
3, most teeth have erupted, and the digestive sys- abilities. Anger, often in the form of “temper tan-
tem is mature enough to handle most adult foods. trums,” occurs when they cannot perform as
Between 2 and 4 years of age, most children learn desired. Children at this age also like routine and
bladder and bowel control. become stubborn, angry, or frustrated when
changes occur. From ages 4–6, children begin to
gain more control over their emotions. They
Mental Development understand the concept of right and wrong, and
Mental development advances rapidly during because they have achieved more independence,
early childhood. Verbal growth progresses from they are not frustrated as much by their lack of
the use of several words at age 1 to a vocabulary ability. By age 6, most children also show less
of 1,500–2,500 words at age 6. Two-year-olds have anxiety when faced with new experiences,
short attention spans but are interested in many because they have learned they can deal with
different activities (figure 8-4). They can remem- new situations.
FIGURE 8-6 Playing alongside and with other

children allows preschoolers to learn how to interact
with others.
FIGURE 8-5 By age two, most children begin to

gain some self-confidence and are enthusiastic
about learning new things. LATE CHILDHOOD
The late childhood life stage, which covers ages
Social Development 6–12, is also called preadolescence. Physical devel-
Social development expands from a self-centered opment is slow but steady. Weight gain averages
1-year-old to a sociable 6-year-old. In the early 4–7 pounds (2.3–3.2 kg) per year, and height usu-
years, children are usually strongly attached to ally increases approximately 2–3 inches (5–7.5
their parents (or to the individuals who provide cm) per year. Muscle coordination is well devel-
their care), and they fear any separation. They oped, and children can engage in physical activi-
begin to enjoy the company of others, but are still ties that require complex motor-sensory
very possessive. Playing alongside other children coordination. During this age, most of the pri-
is more common than playing with other chil- mary teeth are lost, and permanent teeth erupt.
dren (figure 8-6). Gradually, children learn to put The eyes are well developed, and visual acuity is
“self” aside and begin to take more of an interest at its best. During ages 10–12, secondary sexual
in others. They learn to trust other people and characteristics may begin to develop in some
make more of an effort to please others by becom- children.
ing more agreeable and social. Friends of their
own age are usually important to 6-year-olds.
Mental Development
Mental development increases rapidly because
Needs much of the child’s life centers around school.
The needs of early childhood still include food, Speech skills develop more completely, and read-
rest, shelter, protection, love, and security. In ing and writing skills are learned. Children learn
addition, children need routine, order, and con- to use information to solve problems, and the
sistency in their daily lives. They must be taught memory becomes more complex. They begin to
to be responsible and must learn how to conform understand more abstract concepts such as loy-
to rules. This can be accomplished by making alty, honesty, values, and morals. Children use
reasonable demands based on the child’s ability more active thinking and become more adept at
to comply. making judgments (figure 8-7).
242 CHAPTER 8
dren tend to make friends more easily, and they

begin to develop an increasing awareness of the
opposite sex. As children spend more time with
others their own age, their dependency on their
parent(s) lessens, as does the time they spend
with their parents.
Needs
Needs of children in this age group include the
same basic needs of infancy and early childhood,
together with the need for reassurance, parental
approval, and peer acceptance.
ADOLESCENCE
FIGURE 8-7 In late childhood (ages 6–12),
children become more adept at making judgments. Adolescence, ages 12 to 18, is often a traumatic
life stage. Physical changes occur most dramati-
cally in the early period. A sudden “growth spurt”
can cause rapid increases in weight and height. A
Emotional Development weight gain of up to 25 pounds (11 kg) and a
Emotional development continues to help the height increase of several inches can occur in a
child achieve a greater independence and a more period of months. Muscle coordination does not
distinct personality. At age 6, children are often advance as quickly. This can lead to awkwardness
frightened and uncertain as they begin school. or clumsiness in motor coordination. This growth
Reassuring parents and success in school help spurt usually occurs anywhere from ages 11 to 13
children gain self-confidence. Gradually, fears in girls and ages 13 to 15 in boys.
are replaced by the ability to cope. Emotions are The most obvious physical changes in ado-
slowly brought under control and dealt with in a lescents relate to the development of the sexual
more effective manner. By ages 10–12, sexual organs and secondary sexual characteristics, fre-
maturation and changes in body functions can quently called puberty. Secretion of sex hor-
lead to periods of depression followed by periods mones leads to the onset of menstruation in girls
of joy. These emotional changes can cause chil- and the production of sperm and semen in boys.
dren to be restless, anxious, and difficult to under- Secondary sexual characteristics in females
stand. include growth of pubic hair, development of
breasts and wider hips, and distribution of body
fat leading to the female shape. The male devel-
Social Development ops a deeper voice; attains more muscle mass
Social changes are evident during these years. and broader shoulders; and grows pubic, facial,
Seven-year-olds tend to like activities they can do and body hair.
by themselves and do not usually like group
activities. However, they want the approval of
others, especially their parents and friends. Chil- Mental Development
dren from ages 8–10 tend to be more group ori- Since most of the foundations have already been
ented, and they typically form groups with established, mental development primarily
members of their own sex. They are more ready involves an increase in knowledge and a sharp-
to accept the opinions of others and learn to con- ening of skills. Adolescents learn to make deci-
form to rules and standards of behavior followed sions and to accept responsibility for their actions.
by the group. Toward the end of this period, chil- At times, this causes conflict because they are
treated as both children and adults, or are told to behavior that they associate with adult behavior
“grow up” while being reminded that they are or status.
“still children.”
Needs
Emotional Development In addition to basic needs, adolescents need reas-
Emotional development is often stormy and in surance, support, and understanding. Many
conflict. As adolescents try to establish their iden- problems that develop during this life stage can
tities and independence, they are often uncertain be traced to the conflict and feelings of inade-
and feel inadequate and insecure. They worry quacy and insecurity that adolescents experi-
about their appearance, their abilities, and their ence. Examples include eating disorders, drug
relationships with others. They frequently and alcohol abuse, and suicide. Even though
respond more and more to peer group influences. these types of problems also occur in earlier and
At times, this leads to changes in attitude and later life stages, they are frequently associated
behavior and conflict with values previously with adolescence.
established. Toward the end of adolescence, self- Eating disorders often develop from an exces-
identity has been established. At this point, teen- sive concern with appearance. Two common eat-
agers feel more comfortable with who they are ing disorders are anorexia nervosa and bulimia.
and turn attention toward what they may become. Anorexia nervosa, commonly called anorexia,
They gain more control of their feelings and is a psychological disorder in which a person
become more mature emotionally. drastically reduces food intake or refuses to eat at
all. This results in metabolic disturbances, exces-
sive weight loss, weakness, and if not treated,
Social Development death. Bulimia is a psychological disorder in
which a person alternately binges (eats exces-
Social development usually involves spending sively) and then fasts, or refuses to eat at all. When
less time with family and more time with peer a person induces vomiting or uses laxatives to get
groups. As adolescents attempt to develop self- rid of food that has been eaten, the condition is
identity and independence, they seek security called bulimarexia. All three conditions are
in groups of people their own age who have simi- more common in female than male individuals.
lar problems and conflicts (figure 8-8). If these Psychological or psychiatric help is usually
peer relationships help develop self-confidence needed to treat these conditions.
through the approval of others, adolescents Chemical abuse is the use of substances
become more secure and satisfied. Toward the such as alcohol or drugs and the development of
end of this life stage, adolescents develop a more a physical and/or mental dependence on these
mature attitude and begin to develop patterns of chemicals. Chemical abuse can occur in any life
stage, but it frequently begins in adolescence.
Reasons for using chemicals include anxiety or
stress relief, peer pressure, escape from emo-
tional or psychological problems, experimenta-
tion with feelings the chemicals produce, desire
for “instant gratification,” hereditary traits, and
cultural influences. Chemical abuse can lead to
physical and mental disorders and disease. Treat-
ment is directed toward total rehabilitation that
allows the chemical abuser to return to a produc-
tive and meaningful life.
Suicide, found in many life stages, is one of
the leading causes of death in adolescents. Sui-
cide is always a permanent solution to a tempo-
FIGURE 8-8 Adolescents use the peer group as a rary problem. Reasons for suicide include
safety net as they try to establish their identities and depression, grief over a loss or love affair, failure
independence. in school, inability to meet expectations, influ-
244 CHAPTER 8
ence of suicidal friends, or lack of self-esteem.

The risk for suicide increases with a family his-
tory of suicide, a major loss or disappointment,
previous suicide attempts, and/or the recent sui-
cide of friends, family, or role models (heroes or
idols). The impulsive nature of adolescents also
increases the possibility of suicide. Most individ-
uals who are thinking of suicide give warning
signs such as verbal statements like “I’d rather be
dead” or “You’d be better off without me.” Other
warning signs include:
♦ sudden changes in appetite and sleep habits
♦ withdrawal, depression, and moodiness
♦ excessive fatigue or agitation FIGURE 8-9 Early adulthood is the prime child-
bearing time and usually produces the healthiest
♦ neglect of personal hygiene babies.
♦ alcohol or drug abuse
continues for many years. The young adult often
♦ losing interest in hobbies and other aspects of also deals with independence, makes career
life choices, establishes a lifestyle, selects a marital
♦ preoccupation with death partner, starts a family, and establishes values, all
♦ injuring one’s body of which involve making many decisions and
forming many judgments.
♦ giving away possessions
♦ social withdrawal from family and friends
These individuals are calling out for attention
Emotional Development
and help, and usually respond to efforts of assis- Emotional development usually involves pre-
tance. Their direct and indirect pleas should serving the stability established during previous
never be ignored. Support, understanding, and stages. Young adults are subjected to many emo-
psychological or psychiatric counseling are used tional stresses related to career, marriage, family,
to prevent suicide. and other similar situations. If emotional struc-
ture is strong, most young adults can cope with
these worries. They find satisfaction in their
EARLY ADULTHOOD achievements, take responsibility for their ac-
tions, and learn to accept criticism and to profit
from mistakes.
Early adulthood, ages 19–40, is frequently the
most productive life stage. Physical development Social Development
is basically complete, muscles are developed and Social development frequently involves moving
strong, and motor coordination is at its peak. This away from the peer group. Instead, young adults
is also the prime childbearing time and usually tend to associate with others who have similar
produces the healthiest babies (figure 8-9). Both ambitions and interests, regardless of age. The
male and female sexual development is at its young adult often becomes involved with a mate
peak. and forms a family. Young adults do not necessar-
ily accept traditional sex roles and frequently
adopt nontraditional roles. For example, male
Mental Development individuals fill positions as nurses and secretar-
Mental development usually continues through- ies, and female individuals enter administrative
out this stage. Many young adults pursue addi- or construction positions. Such choices have
tional education to establish and progress in their caused and will continue to cause changes in the
chosen careers. Frequently, formal education traditional patterns of society.
MIDDLE ADULTHOOD Emotional Development

Emotionally, middle age can be a period of con-
Physical Development tentment and satisfaction, or it can be a time of
crisis. The emotional foundation of previous life
Middle adulthood, ages 40–65, is frequently called stages and the situations that occur during mid-
middle age. Physical changes begin to occur dur- dle age determine emotional status during this
ing these years. The hair tends to gray and thin, period. Job stability, financial success, the end of
the skin begins to wrinkle, muscle tone tends to child rearing, and good health can all contribute
decrease, hearing loss starts, visual acuity to emotional satisfaction (figure 8-10). Stress,
declines, and weight gain occurs. Women experi- created by loss of job, fear of aging, loss of youth
ence menopause, or the end of menstruation, and vitality, illness, marital problems, or prob-
along with decreased hormone production that lems with children or aging parents, can contrib-
causes physical and emotional changes. Men also ute to emotional feelings of depression, insecurity,
experience a slowing of hormone production. anxiety, and even anger. Therefore, emotional
This can lead to physical and psychological status varies in this age group and is largely deter-
changes, a period frequently referred to as the mined by events that occur during this period.
male climacteric. However, except in cases of
injury, disease, or surgery, men never lose the
ability to produce sperm or to reproduce. Social Development
Social relationships also depend on many factors.
Mental Development Family relationships often see a decline as chil-
dren begin lives of their own and parents die.
Mental ability can continue to increase during Work relationships frequently replace family.
middle age, a fact that has been proved by the Relationships between husband and wife can
many individuals in this life stage who seek for- become stronger as they have more time together
mal education. Middle adulthood is a period and opportunities to enjoy success. However,
when individuals have acquired an understand- divorce rates are also high in this age group, as
ing of life and have learned to cope with many couples who have remained together “for the
different stresses. This allows them to be more children’s sake” now separate. Friendships are
confident in making decisions and to excel at usually with people who have the same interests
analyzing situations. and lifestyles.
LATE ADULTHOOD
Late adulthood, age 65 and older, has many dif-
ferent terms associated with it. These include
“elderly,” “senior citizen,” “golden ager,” and
“retired citizen.” Much attention has been
directed toward this life stage in recent years
because people are living longer, and the number
of people in this age group is increasing daily.
Physical development is on the decline. All
body systems are usually affected. The skin
becomes dry, wrinkled, and thinner. Brown or
yellow spots (frequently called “age spots”)
appear. The hair becomes thin and frequently
FIGURE 8-10 Job stability and enjoyment loses its luster or shine. Bones become brittle and
during middle adulthood contribute to emotional porous, and are more likely to fracture or break.
satisfaction. Cartilage between the vertebrae thins and can
246 CHAPTER 8
lead to a stooping posture. Muscles lose tone and abilities. These diseases are discussed in greater
strength, which can lead to fatigue and poor coor- detail in Chapter 10:4.
dination. A decline in the function of the nervous
system leads to hearing loss, decreased visual
acuity, and decreased tolerance for temperatures Emotional Development
that are too hot or too cold. Memory loss can Emotional stability also varies among individuals
occur, and reasoning ability can diminish. The in this age group. Some elderly people cope well
heart is less efficient, and circulation decreases. with the stresses presented by aging and remain
The kidney and bladder are less efficient. Breath- happy and able to enjoy life. Others become
ing capacity decreases and causes shortness of lonely, frustrated, withdrawn, and depressed.
breath. However, it is important to note that these Emotional adjustment is necessary throughout
changes usually occur slowly over a long period. this cycle. Retirement, death of a spouse and
Many individuals, because of better health and friends, physical disabilities, financial problems,
living conditions, do not show physical changes loss of independence, and knowledge that life
of aging until their seventies and even eighties. must end all can cause emotional distress. The
adjustments that the individual makes during
this life stage are similar to those made through-
Mental Development out life.
Mental abilities vary among individuals. Elderly
people who remain mentally active and are will-
ing to learn new things tend to show fewer signs Social Development
of decreased mental ability (figure 8-11). Although Social adjustment also occurs during late adult-
some 90-year-olds remain alert and well oriented, hood. Retirement can lead to a loss of self-esteem,
other elderly individuals show decreased mental especially if work is strongly associated with self-
capacities at much earlier ages. Short-term mem- identity: “I am a teacher,” instead of “I am Sandra
ory is usually first to decline. Many elderly indi- Jones.” Less contact with coworkers and a more
viduals can clearly remember events that occurred limited circle of friends usually occur. Many
20 years ago, but do not remember yesterday’s elderly adults engage in other activities and con-
events. Diseases such as Alzheimer’s disease tinue to make new social contacts (figure 8-12).
can lead to irreversible loss of memory, deteriora- Others limit their social relationships. Death of a
tion of intellectual functions, speech and gait spouse and friends, and moving to a new envi-
disturbances, and disorientation. Arterioscle- ronment can also cause changes in social rela-
rosis, a thickening and hardening of the walls
of the arteries, can also decrease the blood sup-
ply to the brain and cause a decrease in mental
FIGURE 8-11 Elderly adults who are willing to

learn new things show fewer signs of decreased FIGURE 8-12 Social contacts and activities are
mental ability. important during late adulthood.
tionships. Development of new social contacts is members who provide care to the dying patient
important at this time. Senior centers, golden age know both the extent of information given to the
groups, churches, and many other organizations patient and how the patient reacted.
help provide the elderly with the opportunity to Dr. Kübler-Ross has identified five stages of
find new social roles. grieving that dying patients and their families/
friends may experience in preparation for death.
The stages may not occur in order, and they may
Needs overlap or be repeated several times. Some patients
Needs of this life stage are the same as those of all may not progress through all of the stages before
other life stages. In addition to basic needs, the death occurs. Other patients may be in several
elderly need a sense of belonging, self-esteem, stages at the same time. The stages are denial,
financial security, social acceptance, and love. anger, bargaining, depression, and acceptance.
Denial is the “No, not me!” stage, which usu-
STUDENT: Go to the workbook and complete ally occurs when a person is first told of a termi-
the assignment sheet for 8:1, Life Stages. nal illness. It occurs when the person cannot
accept the reality of death or when the person
feels loved ones cannot accept the truth. The per-
8:2 INFORMATION son may make statements such as “The doctor
does not know what he is talking about” or “The
Death and Dying tests have to be wrong.” Some patients seek sec-
ond medical opinions or request additional tests.
Death is often referred to as “the final stage of Others refuse to discuss their situations and avoid
growth.” It is experienced by everyone and can- any references to their illnesses. It is important
not be avoided. In our society, the young tend to for patients to discuss these feelings. The health
ignore its existence. It is usually the elderly, hav- care worker should listen to a patient and try to
ing lost spouses and/or friends, who begin to provide support without confirming or denying.
think of their own deaths. Statements such as “It must be hard for you” or
When a patient is told that he or she has a “You feel additional tests will help?” will allow the
terminal illness, a disease that cannot be cured patient to express feelings and move on to the
and will result in death, the patient may react in next stage.
different ways. Some patients react with fear and Anger occurs when the patient is no longer
anxiety. They fear pain, abandonment, and lone- able to deny death. Statements such as “Why
liness. They fear the unknown. They become anx- me?” or “It’s your fault” are common. Patients
ious about their loved ones and about unfinished may strike out at anyone who comes in contact
work or dreams. Anxiety diminishes in patients with them and become hostile and bitter. They
who feel they have had full lives and who have may blame themselves, their loved ones, or health
strong religious beliefs regarding life after death. care personnel for their illnesses. It is important
Some patients view death as a final peace. They for the health care worker to understand that this
know it will bring an end to loneliness, pain, and anger is not a personal attack; the anger is caused
suffering. by the situation the patient is experiencing. Pro-
viding understanding and support, listening, and
STAGES OF DYING making every attempt to respond to the patient’s

demands quickly and with kindness is essential
AND DEATH during this stage. This stage continues until the
anger is exhausted or the patient must attend to
Dr. Elizabeth Kübler-Ross has done extensive other concerns.
research on the process of death and dying, and Bargaining occurs when patients accept
is known as a leading expert on this topic. Because death but want more time to live. Frequently, this
of her research, most medical personnel now is a period when patients turn to religion and
believe patients should be told of their approach- spiritual beliefs. At this point, the will to live is
ing deaths. However, patients should be left with strong, and patients fight hard to achieve goals
“some hope” and the knowledge that they will set. They want to see their children graduate or
“not be left alone.” It is important that all staff get married, they want time to arrange care for
248 CHAPTER 8
their families, they want to hold new grandchil-

dren, or other similar desires. Patients make
promises to God to obtain more time. Health care
workers must again be supportive and be good
listeners. Whenever possible, they should help
patients meet their goals.
Depression occurs when patients realize
that death will come soon and they will no longer
be with their families or be able to complete their
goals. They may express these regrets, or they
may withdraw and become quiet (figure 8-13).
They experience great sadness and, at times,
overwhelming despair. It is important for health
care workers to let patients know that it is “OK” to
be depressed. Providing quiet understanding,
support, and/or a simple touch, and allowing
patients to cry or express grief are important dur- FIGURE 8-14 The support and presence of
ing this stage. others is important to the dying person.
Acceptance is the final stage. Patients under-
stand and accept the fact that they are going to can be one of the greatest satisfactions a health
die. Patients may complete unfinished business care worker can experience. To be able to provide
and try to help those around them deal with the this care, however, health care workers must first
oncoming death. Gradually, patients separate understand their own personal feelings about
themselves from the world and other people. At death and come to terms with these feelings.
the end, they are at peace and can die with dig- Feelings of fear, frustration, and uncertainty
nity. During this final stage, patients still need about death can cause workers to avoid dying
emotional support and the presence of others, patients or provide superficial, mechanical care.
even if it is just the touch of a hand (figure 8-14). With experience, health care workers can find
ways to deal with their feelings and learn to pro-
vide the supportive care needed by the dying.
HOSPICE CARE Hospice care can play an important role in
meeting the needs of the dying patient. Hospice
Providing care to dying patients can be very dif- care offers palliative care, or care that provides
ficult, but very rewarding. Providing supportive support and comfort. It can be offered in hospi-
care when families and patients require it most tals, medical centers, and special facilities, but
most frequently it is offered in the patient’s home.
Hospice care is not limited to a specific time
period in a patient’s life. Usually it is not started
until a physician declares that the patient has
6 months or less to live, but it can be started
sooner. Most often patients and their families are
reluctant to begin hospice care because they feel
that this action recognizes the end of life. They
seem to feel that if they do not use hospice care
until later, death will not be as near as it actually
is. The philosophy behind hospice care is to allow
the patient to die with dignity and comfort. Using
palliative measures of care and the philosophy of
death with dignity provides patients and families
with many comforts and provides an opportunity
to find closure. Some of the comforts provided by
FIGURE 8-13 Depression can be a normal stage hospice may include providing hospital equip-
of grieving in a dying patient. ment such as beds, wheelchairs, and bedside
commodes; offering psychological, spiritual, Health care workers must be aware that a
social, and financial counseling; and providing dying person has rights that must be honored. A
free or less expensive pain medication. Pain is Dying Person’s Bill of Rights was created at a
controlled so that the patient can remain active workshop sponsored by the South Western Mich-
as long as possible. In medical facilities, personal igan Inservice Education Council. This bill of
care of the patient is provided by the staff; in the rights states:
home situation, this care is provided by home
health aides and other health care professionals. ♦ I have the right to be treated as a living human
Specially trained volunteers are an important being until I die.
part of many hospice programs. They make regu- ♦ I have the right to maintain a sense of hope-
lar visits to the patient and family, stay with the fulness, however changing its focus may be.
patient while the family leaves the home for brief ♦ I have the right to be cared for by those who
periods of time, and help provide the support and can maintain a sense of hopefulness, however
understanding that the patient and family need. challenging this might be.
When the time for death arrives, the patient is
allowed to die with dignity and in peace. After the
♦ I have the right to express my feelings and
emotions about my approaching death in my
death of the patient, hospice personnel often
own way.
maintain contact with the family during the ini-
tial period of mourning. ♦ I have the right to participate in decisions
concerning my care.
♦ I have the right to expect continuing medical
RIGHT TO DIE and nursing attention even though “cure”
The right to die is another issue that health goals must be changed to “comfort” goals.
care workers must understand. Because ♦ I have the right not to die alone.
health care workers are ethically concerned with ♦ I have the right to be free from pain.
promoting life, allowing patients to die can cause
conflict. However, a large number of surveys have
♦ I have the right to have my questions answered
honestly.
shown that most people feel that an individual
who has a terminal illness, with no hope of being ♦ I have the right not to be deceived.
cured, should be allowed to refuse measures that ♦ I have the right to have help from and for my
would prolong life. This is called the right to die. family in accepting my death.
Most states have passed, or are now creating, laws
that allow adults who have terminal illnesses to
♦ I have the right to die in peace and with dig-
nity.
instruct their doctors, in writing, to withhold
treatments that might prolong life. Most of the ♦ I have the right to maintain my individuality
laws involve the use of advance directives, dis- and not be judged for my decisions, which
cussed in Chapter 5:4. Under these laws, specific may be contrary to the beliefs of others.
actions to end life cannot be taken. However, the ♦ I have the right to expect that the sanctity of
use of respirators, pacemakers, and other medical the human body will be respected after
devices can be withheld, and the person can be death.
allowed to die with dignity.
♦ I have the right to be cared for by caring, sen-
Hospices throughout the nation are encour-
sitive, knowledgeable people who will attempt
aging individuals to make their end-of-life wishes
to understand my needs and will be able to
known through the LIVE promise. This promise
gain some satisfaction in helping me face my
encourages individuals to:
death.
♦ Learn about end-of-life services and care ♦ I have the right to discuss and enlarge my reli-
♦ Implement plans or advanced directives to gious and/or spiritual experiences, whatever
ensure wishes are honored these may mean to others.
♦ Voice decisions Health care workers deal with death and with
♦ Engage others in conversations about end-of- dying patients because death is a part of life. By
life care options understanding the process of death and by think-
250 CHAPTER 8
ing about the needs of dying patients, the health

care worker will be able to provide the special MASLOW’S HIERARCHY
care needed by these individuals.
OF NEEDS
STUDENT: Go to the workbook and complete Abraham Maslow, a noted psychologist, devel-
the assignment sheet for 8:2, Death and Dying. oped a hierarchy of needs (figure 8-15). Accord-
ing to Maslow, the lower needs should be met
before an individual can strive to meet higher
8:3 INFORMATION needs. Only when satisfaction has been obtained
at one level is an individual motivated toward
Human Needs meeting needs at a higher level. The levels of
Needs are frequently defined as “a lack of some- needs include physiological needs, safety, affec-
thing that is required or desired.” From the tion, esteem, and self-actualization.
moment of birth to the moment of death, every
human being has needs. Needs motivate the indi-
vidual to behave or act so that these needs will be Physiological Needs
met, if at all possible. Physiological needs are often called “physi-
Certain needs have priority over other needs. cal,” “biological,” or “basic” needs. These needs
For example, at times a need for food may take are required by every human being to sustain life.
priority over a need for social approval, or the They include food, water, oxygen, elimination of
approval of others. If individuals have been with- waste materials, sleep, and protection from
out food for a period of time, they will direct most extreme temperatures. These needs must be met
of their actions toward obtaining food. Even for life to continue. If any of these needs goes
though they want social approval and the respect unmet, death will occur. Even among these needs,
of others, they may steal for food, knowing that a priority exists. For example, because lack of
stealing may cause a loss of social approval or oxygen will cause death in a matter of minutes,
respect. the need for oxygen has priority over the need for
Self-Actualization
Obtain full potential,
Confident, Self secure
Esteem
Self respect,
Has approval of others
Love and affection

Feel sense of belonging,
Can give and receive friendship and love
Safety and security

Free from fear and anxiety,
Feel secure in the environment
Physiological needs
Food, Water, Oxygen, Elimination of waste
Protection from temperature extremes, Sleep
FIGURE 8-15 Maslow’s Hierarchy of Needs: the lower needs should be met before the individual can try to
meet higher needs.
food. A patient with severe lung disease who is Safety

gasping for every breath will not be concerned
with food intake. This individual’s main concern Safety becomes important when physiological
will be to obtain enough oxygen to live through needs have been met. Safety needs include
the next minute. the need to be free from anxiety and fear, and the
Other physiological needs include sensory need to feel secure in the environment. The need
and motor needs. If these needs are not met, for order and routine is another example of an
individuals may not die, but their body functions individual’s effort to remain safe and secure. Indi-
will be affected. Sensory needs include hearing, viduals often prefer the familiar over the unknown.
seeing, feeling, smelling, tasting, and mental New environments, a change in routine, marital
stimulation. When these needs are met, they problems, job loss, injury, disease, and other sim-
allow the individual to respond to the environ- ilar events can threaten an individual’s safety.
ment. If these needs are not met, the person may Illness is a major threat to an individual’s
lose contact with the environment or with real- security and well-being. Health care workers are
ity. An example is motor needs, which include familiar with laboratory tests, surgeries, medica-
the ability to move and respond to the individu- tions, and therapeutic treatments. Patients are
al’s environment. If muscles are not stimulated, usually frightened when they are exposed to them
they will atrophy (waste away), and function will and their sense of security is threatened. If health
be lost. care workers explain the reason for the tests or
Many of the physiological needs are auto- treatments and the expected outcomes to the
matically controlled by the body. The process of patient, this can frequently alleviate the patient’s
breathing is usually not part of the conscious anxieties. Patients admitted to a health care facil-
thought process of the individual until something ity or long-term care facility must adapt to a
occurs to interfere with breathing. Another strange and new environment. They frequently
example is the functioning of the urinary blad- experience anxiety or depression. Patients may
der. The bladder fills automatically, and the indi- also experience depression over the loss of health
vidual only becomes aware of the bladder when it or loss of a body function. Health care workers
is full. If the individual does not respond and go must be aware of the threats to safety and secu-
to the restroom to empty the bladder, eventually rity that patients are experiencing, and make
control will be lost and the bladder will empty every effort to explain procedures, provide sup-
itself. port and understanding, and help patients adapt
Health care workers must be aware of how an to the situation.
illness interferes with meeting physiological
needs. A patient scheduled for surgery or labora-
tory tests may not be allowed to eat or drink
Love and Affection
before the procedure. Anxiety about an illness The need for love and affection, a warm and
may interfere with a patient’s sleep or elimina- tender feeling for another person, occupies the
tion patterns. Medications may affect a patient’s third level of Maslow’s Hierarchy of Needs. When
appetite. Elderly individuals are even more likely an individual feels safe and secure, and after all
to have difficulty meeting physiological needs. A physiological needs have been met, the individ-
loss of vision or hearing due to aging may make it ual next strives for social acceptance, friendship,
difficult for an elderly person to communicate and to be loved. The need to belong, to relate to
with others. A decreased sense of smell and taste others, and to win approval of others motivates
can affect appetite. Deterioration of muscles and an individual’s actions at this point. The individ-
joints can lead to poor coordination and difficulty ual may now attend a social function that was
in walking. Any of these factors can cause a avoided when safety was more of a priority. Indi-
change in a person’s behavior. If health care work- viduals who feel safe and secure are more willing
ers are aware that physiological needs are not to accept and adapt to change and are more will-
being met, they can provide understanding and ing to face unknown situations. The need for love
support to the patient and make every effort to and affection is satisfied when friends are made,
help the patient satisfy the needs. social contacts are established, acceptance by
252 CHAPTER 8
others is received, and the individual is able to cease in late adulthood. Long-term care facilities
both give and receive affection and love (figure are recognizing this fact by allowing married cou-
8-16). ples to share a room, instead of separating people
Maslow states that sexuality is both a part of according to sex. Even after the death of a spouse,
the need for love and affection, as well as a physi- an individual may develop new relationships.
ological need. Sexuality in this context is defined Determining what role sexuality will play in a
by people’s feelings concerning their masculine/ person’s life is a dynamic process that allows peo-
feminine natures, their abilities to give and ple to meet their need for love and affection
receive love and affection, and finally, their roles throughout their life.
in reproduction of the species. It is important to Sexuality, in addition to being related to the
note that in all three of these areas, sexuality satisfaction of needs, is also directly related to an
involves a person’s feelings and attitudes, not just individual’s moral values. Issues such as the
the person’s sexual relationships. appropriateness of sex before marriage, the use
It is equally important to note that a person’s of birth control, how to deal with pregnancy, and
sexuality extends throughout the life cycle. At how to deal with sexually transmitted diseases all
conception, a person’s sexual organs are deter- require individuals to evaluate their moral beliefs.
mined. Following birth, a person is given a name, These beliefs then serve as guidelines to help
at least generally associated with the person’s sex. people reach decisions on their behaviors.
Studies have shown that children receive treat- Some individuals use sexual relationships as
ment according to gender from early childhood substitutes for love and affection. Individuals who
and frequently are rewarded for behavior that is seek to meet their needs only in this fashion can-
deemed “gender appropriate.” With the onset of not successfully complete Maslow’s third level.
puberty, adolescents become more aware of their
emerging sexuality and of the standards that soci-
ety places on them. During both childhood and
adolescence, much of what is learned about sex-
Esteem
uality comes from observing adult role models. Maslow’s fourth level includes the need for
As the adolescent grows into young adulthood, esteem. Esteem includes feeling important and
society encourages a reexamination of sexuality worthwhile. When others show respect, approval,
and the role it plays in helping to fulfill the need and appreciation, an individual begins to feel
for love and affection. In adulthood, sexuality esteem and gains self-respect. The self-concept,
develops new meanings according to the roles or beliefs, values, and feelings people have about
that the adult takes on. Sexuality needs do not themselves, becomes positive. Individuals will
engage in activities that bring achievement, suc-
cess, and recognition in an effort to maintain
their need for esteem. Failure in an activity can
cause a loss of confidence and lack of esteem.
When esteem needs are met, individuals gain
confidence in themselves and begin to direct
their actions toward becoming what they want
to be.
Illness can have a major effect on esteem.
When self-reliant individuals, competent at mak-
ing decisions, find themselves in a health care
facility and dependent on others for basic care
such as bathing, eating, and elimination, they
can experience a severe loss of esteem. They may
also worry about a lack of income, possible job
loss, the well-being of their family, and/or the
possibility of permanent disability or death.
Patients may become angry and frustrated or
FIGURE 8-16 Individuals of all ages need love quiet and withdrawn. Health care workers must
and affection. (Courtesy of Sandy Clark) recognize this loss of esteem and make every
attempt to listen to the patient, encourage as work at reducing the need or relieving the tension
much independence as possible, provide sup- and frustration created by the unmet need.
portive care, and allow the person to express
anger or fear.
Direct Methods
Self-Actualization Direct methods include:
Self-actualization, frequently called self-realiza- ♦ hard work

tion, is the final need in Maslow’s hierarchy. All ♦ realistic goals
other needs must be met, at least in part, before ♦ situation evaluation
self-actualization can occur. Self-actualization
means that people have obtained their full poten- ♦ cooperation with others
tials, or that they are what they want to be. People All these methods are directed toward meeting
at this level are confident and willing to express the need. Students who constantly fail tests but
their beliefs and stick to them. They feel so strongly who want to pass a course have a need for suc-
about themselves that they are willing to reach cess. They can work harder by listening more in
out to others to provide assistance and support. class, asking questions on points they do not
understand, and studying longer for the tests.
They can set realistic goals that will allow them to
MEETING NEEDS find success. By working on one aspect of the
course at a time, by concentrating on new mate-
When needs are felt, individuals are motivated rial for the next test, by planning to study a little
(stimulated) to act. If the action is successful and each night rather than studying only the night
the need is met, satisfaction, or a feeling of before a test, and by working on other things that
pleasure or fulfillment, occurs. If the need is not will enable them to pass, they can establish goals
met, tension, or frustration, an uncomfortable they can achieve. They can evaluate the situation
inner sensation or feeling, occurs. Several needs to determine why they are failing and to try to
can be felt at the same time, so individuals must find other ways to pass the course. They may
decide which needs are stronger. For example, if determine that they are always tired in class and
individuals need both food and sleep, they must that by getting more sleep, they will be able to
decide which need is most important, because learn the material. They can cooperate with oth-
an individual cannot eat and sleep at the same ers. By asking the teacher to provide extra assis-
time. tance, by having parents or friends question them
Individuals feel needs at different levels of on the material, by asking a counselor to help
intensity. The more intense a need, the greater them learn better study habits, or by having a
the desire to meet or reduce the need. Also, when tutor provide extra help, they may learn the mate-
an individual first experiences a need, the indi- rial, pass the tests, and achieve satisfaction by
vidual may deal with it by trying different actions meeting their need.
in a trial-and-error manner, a type of behavior
frequently seen in very young children. As they
grow older, children learn more effective means
of meeting the need and are able to satisfy the
Indirect Methods
need easily. Indirect methods of dealing with needs usually
reduce the need and help relieve the tension cre-
ated by the unmet need. The need is still present,
METHODS OF but its intensity decreases. Defense mecha-
SATISFYING HUMAN nisms, unconscious acts that help a person deal
with an unpleasant situation or socially unac-
NEEDS ceptable behavior, are the main indirect methods
used. Everyone uses defense mechanisms to
Needs can be satisfied by direct or indirect meth- some degree. Defense mechanisms provide
ods. Direct methods work at meeting the need methods for maintaining self-esteem and reliev-
and obtaining satisfaction. Indirect methods ing discomfort. Some use of defense mechanisms
254 CHAPTER 8
is helpful because it allows individuals to cope education. So she changed her educational
with certain situations. However, defense mecha- plans and became a physician’s assistant.
nisms can be unhealthy if they are used all the Compensation was an efficient defense mech-
time and individuals substitute them for more anism because she enjoyed her work and
effective ways of dealing with situations. Being found satisfaction.
aware of the use of defense mechanisms and the ♦ Daydreaming: This is a dreamlike thought
reason for using them is a healthy use. This allows process that occurs when a person is awake.
the individual to relieve tension while modifying Daydreaming provides a means of escape
habits, learning to accept reality, and striving to when a person is not satisfied with reality. If it
find more efficient ways to meet needs. allows a person to establish goals for the future
Examples of defense mechanisms include: and leads to a course of action to accomplish
those goals, it is a good defense mechanism.
♦ Rationalization: This involves using a rea- However, if daydreaming is a substitute for
sonable excuse or acceptable explanation for reality, and the dreams become more satisfy-
behavior to avoid the real reason or true moti- ing than actual life experiences, it can contrib-
vation. For example, a patient who fears hav- ute to a poor adjustment to life. For example,
ing laboratory tests performed may tell the if a person dreams about becoming a dental
health worker, “I can’t take time off from my hygienist and takes courses and works toward
job,” rather than admit fear. this goal, daydreaming is effective. If the per-
♦ Projection: This involves placing the blame son dreams about the goal but is satisfied by
for one’s own actions or inadequacies on the thoughts and takes no action, the person
someone else or on circumstances rather than will not achieve the goal and is simply escap-
accepting responsibility for the actions. Exam- ing from reality.
ples include, “The teacher failed me because ♦ Repression: This involves the transfer of
she doesn’t like me,” rather than “I failed unacceptable or painful ideas, feelings, and
because I didn’t do the work”; and “I’m late thoughts into the unconscious mind. An indi-
because the alarm clock didn’t go off,” rather vidual is not aware that this is occurring. When
than “I forgot to set the alarm clock, and I feelings or emotions become too painful or
overslept.” When people use projection to frightening for the mind to deal with, repres-
blame others, they avoid having to admit that sion allows the individual to continue func-
they have made mistakes. tioning and to “forget” the fear or feeling.
♦ Displacement: This involves transferring Repressed feelings do not vanish, however.
feelings about one person to someone else. They can resurface in dreams or affect behav-
Displacement usually occurs because individ- ior. For example, a person is terrified of heights
uals cannot direct the feelings toward the per- but does not know why. It is possible that a
son who is responsible. Many people fear frightening experience regarding heights hap-
directing hostile or negative feelings toward pened in early childhood and that the experi-
their bosses or supervisors because they fear ence was repressed.
job loss. They then direct this anger toward ♦ Suppression: This is similar to repression,
coworkers and/or family members. The clas- but the individual is aware of the unacceptable
sic example is the man who is mad at his boss. feelings or thoughts and refuses to deal with
When the man gets home, he yells at his wife them. The individual may substitute work, a
or children. In such a case, a constructive talk hobby, or a project to avoid the situation. For
with the boss may solve the problem. If not, or example, a woman ignores a lump in her breast
if this is not possible, physical activity can and refuses to go to a doctor. She avoids think-
help work off hostile or negative feelings. ing about the lump by working overtime and
♦ Compensation: This involves the substitu- joining a health club to exercise during her
tion of one goal for another goal to achieve spare time. This type of behavior creates exces-
success. If a substitute goal meets needs, this sive stress, and eventually the individual will
can be a healthy defense mechanism. For be forced to deal with the situation.
example, Joan wanted to be a doctor, but she ♦ Denial: This involves disbelief of an event or
did not have enough money for a medical idea that is too frightening or shocking for a

An artificial bone that grows?
Bone cancer is rare, but when it occurs, it usually happens in children and young adults.
Common sites are the knee or leg bones. Amputation of the leg was once the only hope for
a cure. Then surgeons began to cut out the tumors and use metal rods to replace the dam-
aged bones. The only problem with this treatment was that the bones did not grow with the
child. Every few years, additional surgery was required to replace the metal rods with longer
rods.
Now researchers in France have invented Repiphysis, a “growable” metal rod. Repiphysis
contains a spring that is held together by a polymer sleeve hooked to an antenna. Harmless
electromagnetic rays are beamed at the leg. These rays cause the antenna to create heat. The
heat softens the polymer sleeve and the spring loosens. This allows the ends of the metal rod
to extend slowly. When the rod has “grown” to the correct length, and the leg matches the
growth of the child’s other leg, the electromagnetic beam is turned off. In seconds, the poly-
mer sleeve hardens and the metal rod is frozen at its new length. The best feature of the
procedure is that it is painless and can be done in a physician’s office.
person to cope with. Often, an individual is

not aware that denial is occurring. Denial fre-
quently occurs when a terminal illness is diag-
nosed. The individual will say that the doctor
is wrong and seek another opinion. When the
individual is ready to deal with the event or
idea, denial becomes acceptance.
♦ Withdrawal: There are two main ways with-
drawal can occur: individuals can either cease
to communicate or remove themselves physi-
cally from a situation (figure 8-17). Withdrawal
is sometimes a satisfactory means of avoiding
conflict or an unhappy situation. For example,
if you are forced to work with an individual
you dislike and who is constantly criticizing
your work, you can withdraw by avoiding any
and all communication with this individual,
quitting your job, or asking for a transfer to
another area. At times, interpersonal conflict FIGURE 8-17 Refusing to communicate is a sign
cannot be avoided, however. In these cases, an of withdrawal.
open and honest communication with the
individual may lead to improved understand-
ing in the relationship.
It is important for health care workers to be care workers will be better able to understand
aware of both their own and patients’ needs. By their own behavior and the behavior of others.
recognizing needs and understanding the actions
individuals take to meet needs, more efficient STUDENT: Go to the workbook and complete
and higher quality care can be provided. Health the assignment sheet for 8:3, Human Needs.
256 CHAPTER 8
2. Stages of human growth and development:

CHAPTER 8 SUMMARY search words such as infancy, childhood,
adolescence, puberty, and adulthood to obtain
Human growth and development is a process information on each stage
that begins at birth and does not end until death. 3. Eating disorders: search for statistics; signs and
Each individual passes through certain stages of symptoms; and treatment of anorexia nervosa,
growth and development, frequently called life bulimia, and bulimarexia
stages. Each stage has its own characteristics
4. Chemical or drug abuse: search for statistics,
and has specific developmental tasks that an
signs/symptoms, and treatment of chemical
individual must master. Each stage also estab-
and drug abuse (Hint: use words such as
lishes the foundation for the next stage.
alcoholism and cocaine.)
Death is often called “the final stage of
growth.” Dr. Elizabeth Kübler-Ross has identified 5. Suicide: search for statistics, signs/symptoms,
five stages that dying patients and their families and ways to prevent suicide
may experience before death. These stages are
6. Death and dying: search for information on Dr.
denial, anger, bargaining, depression, and ac-
Kübler-Ross, hospice care, palliative treatment,
ceptance. The health care worker must be aware
advance directives, and the right to die
of these stages to provide supportive care to the
dying patient. In addition, the health care work- 7. Maslow’s hierarchy of needs: search for addi-
er must understand the concepts represented by tional information on each of the five levels of
hospice care and the right to die. needs
Each life stage creates needs that must be 8. Defense mechanisms: search for specific
met by the individual. Abraham Maslow, a noted information on rationalization, projection,
psychologist, developed a hierarchy of needs displacement, compensation, daydreaming,
that is frequently used to classify and define the repression, suppression, denial, and with-
needs experienced by human beings. The needs drawal
are classified into five levels, and according to
Maslow, the lower needs must be met before an
individual can strive to meet the higher needs. REVIEW QUESTIONS
The needs, beginning at the lowest level and
progressing to the highest, are physiological, or
1. Differentiate between growth and develop-
physical, needs; safety and security; love and af-
ment.
fection; esteem; and self-actualization.
Needs are met or satisfied by direct and in- 2. List the seven (7) life stages and at least two (2)
direct methods. Direct methods meet and elimi- physical, mental, emotional, and social devel-
nate a need. Indirect methods, usually the use of opments that occur in each stage.
defense mechanisms, reduce the need and help
3. Create an example for what a patient and/or
relieve the tension created by the unmet need.
family member might say or do during each of
Mastering these concepts will allow health
the five (5) stages of death and dying.
care workers to develop good interpersonal re-
lationships and provide more effective health 4. Explain what is meant by the “right to die.” Do
care. you believe in this right? Why or why not?
5. Identify each level of Maslow’s Hierarchy of
Needs and give examples of specific needs at
INTERNET SEARCHES each level.
Use the suggested search engines in Chapter 12:4 6. Create a specific example for each of the
of this textbook to search the Internet for addi- following defense mechanisms: rationaliza-
tional information on the following topics: tion, projection, displacement, compensation,
daydreaming, repression, suppression, denial,
1. Erikson’s stages of psychosocial development:
and withdrawal.
search for more details and examples of the
stages of development
CHAPTER 9 Cultural Diversity
Chapter Objectives
Observe Standard ◆ List the four basic characteristics of culture
Precautions
⽧ Differentiate between culture, ethnicity, and
race
Instructor’s Check—Call ⽧ Identify some of the major ethnic groups in the
United States
⽧ Provide an example of acculturation in the
Safety—Proceed with United States
Caution ⽧ Create an example of how a bias, prejudice, or
stereotype can cause a barrier to effective
relationships with others
on Federal Law ⽧ Describe at least five ways to avoid bias,
prejudice, and stereotyping
⽧ Differentiate between a nuclear family and an
Math Skill
extended family
⽧ Identify ways in which language, personal
Legal Responsibility space, touching, eye contact, and gestures are
affected by cultural diversity
Science Skill
⽧ Compare and contrast the diverse health
beliefs of different ethnic/cultural groups
⽧ List five ways health care providers can show
Career Information respect for an individual’s religious beliefs
⽧ Identify methods that can be used to show
Communications Skill respect for cultural diversity
⽧ Define, pronounce, and spell all
key terms
Technology
258 CHAPTER 9
KEY TERMS
acculturation ethnocentric personal space
agnostic extended family prejudice
atheist holistic care race
bias matriarchal (may⬘-tree-ar⬙- religion
cultural assimilation kel) sensitivity
cultural diversity nuclear family spirituality
culture patriarchal (pay⬘-tree-ar⬙-kel) stereotyping
ethnicity
9:1 INFORMATION adults and developing attitudes accepted by

others.
Culture, Ethnicity, and Race ♦ Culture is shared: Common practices and
Health care providers must work with and pro- beliefs are shared with others in a cultural
vide care to many different people. At the same group.
time, they must respect the individuality of each ♦ Culture is social in nature: Individuals in the
person. Therefore, every health care provider cultural group understand appropriate behav-
must be aware of the factors that cause each indi- ior based on traditions that have been passed
vidual to be unique. Uniqueness is influenced by from generation to generation.
many things including physical characteristics ♦ Culture is dynamic and constantly changing:
(sex, body size, and hair, nail, and skin color), New ideas may generate different standards
family life, socioeconomic status, religious beliefs, for behavior. This allows a cultural group to
geographical location, education, occupation, meet the needs of the group by adapting to
and life experiences. A major influence on any environmental changes.
individual’s uniqueness is the person’s cultural/
Ethnicity is a classification of people based
ethnic heritage.
on national origin and/or culture. Members of an
Culture is defined as the values, beliefs, atti-
ethnic group may share a common heritage, geo-
tudes, languages, symbols, rituals, behaviors, and
graphic location, social customs, language, and
customs unique to a particular group of people
beliefs. Even though every individual in an ethnic
and passed from one generation to the next. It is
group may not practice all of the beliefs of the
often defined as a set of rules, because culture
group, the individual is still influenced by other
provides an individual with a blueprint or general
members of the group. There are many different
design for living. Family relations, child rearing,
ethnic groups in the United States (figure 9-1).
education, occupational choice, social interac-
Some of the common ethnic groups and their
tions, spirituality, religious beliefs, food prefer-
countries of origin include:
ences, health beliefs, and health care are all
influenced by culture. Culture is not uniform ♦ African American: Central and South African
among all members within a cultural group, but countries, Dominican Republic, Haiti, and
it does provide a foundation for behavior. Even Jamaica
though differences exist between cultural groups ♦ Asian/Pacific American: Cambodia, China,
and in individuals within a cultural group, all cul- Guam, Hawaii, India, Indonesia and Pacific
tures have four basic characteristics: Island countries, Japan, Korea, Laos, Philip-
♦ Culture is learned: Culture does not just hap- pines, Samoa, and Vietnam
pen. It is taught to others. For example, chil- ♦ European American: England, France, Ger-
dren learn patterns of behavior by imitating many, the Netherlands, Ireland, Italy, Norway,
Cultural Diversity 259
FIGURE 9-1 The many faces of the United States.
Poland, Russia, Scandinavia, Scotland, and and behaviors learned from the ethnic/cultural
Switzerland group that generally account for the behaviors
attributed to race. For example, blacks from Africa
♦ Hispanic American: Cuba, Mexico, Puerto
and blacks from the Caribbean both share many
Rico, Spain, and Spanish-speaking countries
of the same physical characteristics, but they
in Central and South America
have different cultural beliefs and values. In addi-
♦ Middle Eastern/Arabic Americans: Egypt, Iran, tion, there are different races present in most eth-
Iraq, Jordan, Kuwait, Lebanon, Palestine, Saudi nic groups. For example, there are white and
Arabia, Yemen, and other North African and black Hispanics, white Africans and Caribbeans,
Middle Eastern countries and white and black Asians.
Culture, ethnicity, and race do influence an
♦ Native American: more than 500 tribes of
individual’s behavior, self-perception, judgment
American Indians and Eskimos
of others, and interpersonal relationships. These
It is important to recognize that within each differences based on cultural, ethnic, and racial
of the ethnic groups, there are numerous sub- factors are called cultural diversity. It is impor-
groups, each with its own lifestyle and beliefs. For tant to remember that differences exist within
example, the European American group includes ethnic/cultural groups and in individuals within
Italians and Germans, two groups with different a group. In previous times, the United States has
languages and lifestyles. often been called a “melting pot” to represent the
Race is a classification of people based on absorption of many cultures into the dominant
physical or biological characteristics such as the culture through a process called cultural assim-
color of skin, hair, and eyes; facial features; blood ilation. Cultural assimilation requires that the
type; and bone structure. Race is frequently used newly arrived cultural group alter unique beliefs
to label a group of people and explain patterns of and behaviors and adopt the ways of the domi-
behavior. In reality, race cuts across multiple eth- nant culture. In reality, the United States is striv-
nic/cultural groups, and it is the values, beliefs, ing to be more like a “salad bowl” where cultural
260 CHAPTER 9
differences are appreciated and respected. The

simultaneous existence of various ethnic/cul- 9:2 INFORMATION
tural groups gives rise to a “multicultural” society
that must recognize and respect many different
Bias, Prejudice, and Stereotyping
beliefs. Acculturation, or the process of learn- Bias, prejudice, and stereotyping can interfere
ing the beliefs and behaviors of a dominant cul- with acceptance of cultural diversity. A bias is a
ture and assuming some of the characteristics, preference that inhibits impartial judgment. For
does occur. However, acculturation occurs slowly example, individuals who believe in the suprem-
over a long period, usually many years. Recent acy of their own ethnic group are called ethno-
immigrants to the United States are more likely to centric. These individuals believe that their
use the language and follow the patterns of cultural values are better than the cultural values
behavior of the country from which they emi- of others, and may antagonize and alienate peo-
grated. Second- and third-generation Americans ple from other cultures. Individuals may also be
are more likely to use English as their main lan- biased with regard to other factors. Examples of
guage and follow the patterns of behavior preva- common biases include:
lent in the United States (figure 9-2).
Because they provide care to culturally diverse
♦ Age: Young people are physically and mentally
superior to older people.
patients in a variety of settings, health care pro-
viders must be aware of these factors and remem- ♦ Education: College-educated individuals are
ber that no individual is 100 percent anything! superior to uneducated individuals.
Every individual has and will continue to create ♦ Economic: Rich people are superior to poor
new and changing blends of values and beliefs. people.
Sensitivity, the ability to recognize and appreci-
♦ Physical size: Obese and short people are infe-
ate the personal characteristics of others, is
rior.
essential in health care. For example, in some
cultures such as Native Americans or Asians, call- ♦ Occupation: Nurses are inferior to doctors.
ing an adult by a first name is not acceptable ♦ Sexual preference: Homosexuals are inferior to
except for close friends or relatives. Sensitive heterosexuals.
health care workers will address patients by their
♦ Gender: Women are inferior to men.
last names unless they are asked to use a patient’s
first name. Prejudice means to prejudge. A prejudice is
a strong feeling or belief about a person or sub-
ject that is formed without reviewing facts or
information. Prejudiced individuals regard their
ideas or behavior as right and other ideas or
behavior as wrong. They are frequently afraid of
things that are different. Prejudice causes fear
and distrust and interferes with interpersonal
relationships. Every individual is prejudiced to
some degree. We all want to feel that our beliefs
are correct. In health care, however, it is impor-
tant to be aware of our prejudices and to make
every effort to obtain as much information about
a situation as possible. This allows us to learn
about other individuals, understand their beliefs,
and communicate successfully.
Stereotyping occurs when an assumption is
made that everyone in a particular group is the
FIGURE 9-2 Second- or third-generation individu- same. A stereotype ignores individual character-
als in the same ethnic/cultural group will adopt istics and “labels” an individual. A classic exam-
many patterns of behavior dominant in the United ple is, “All blondes are dumb.” This stereotype has
States. been perpetuated by “blonde jokes” detrimental
to individuals who have light colored hair. Similar

stereotypes exist with regard to race, sex, body FAMILY ORGANIZATION
size (thin, obese, short, or tall), occupation, and
Family organization refers to the structure of a
ethnic/cultural group. It is essential to remember
family and the dominant or decision-making
that everyone is a unique individual. Each person
person in a family. Families vary in their compo-
will have different life experiences and exposure
sition and in the roles assumed by family mem-
to other cultures and ideas. This allows a person
bers. A nuclear family usually consists of a
to develop a unique personality and lifestyle.
mother, father, and children (figure 9-3). It may
Bias, prejudice, and stereotyping are barriers
also consist of a single parent and child(ren). An
to effective relationships with others. Health care
extended family includes the nuclear family
providers must be alert to these barriers and
plus grandparents, aunts, uncles, and cousins
make every effort to avoid them. Some ways to
(figure 9-4). The nuclear family is usually the
avoid bias, prejudice, and stereotyping include:
basic unit in European American families, but
♦ Know and be consciously aware of your own the extended family is important. The basic unit
personal and professional values and beliefs. for Asian, Hispanic, and Native Americans is gen-
♦ Obtain as much information as possible about erally the extended family, and frequently, several
different ethnic/cultural groups. different generations live in the same household.
This affects care of children, the sick, and the
♦ Be sensitive to behaviors and practices differ-
elderly. In extended family cultures, families tend
ent from your own.
♦ Remember that you are not being pressured to
adopt other beliefs, but that you must respect
them.
♦ Develop friendships with a wide variety of
people from different ethnic/cultural groups.
♦ Ask questions and encourage questions from
others to share ideas and beliefs.
♦ Evaluate all information before you form an
opinion.
♦ Be open to differences.
♦ Avoid jokes that may offend.
♦ Remember that mistakes happen. Apologize if FIGURE 9-3 A nuclear family usually consists of a
you hurt another person, and forgive if another mother, father, and children.
person hurts you.
9:3 INFORMATION
Understanding Cultural Diversity
The cultural and ethnic beliefs of an individual
will affect the behavior of the individual. Health
care providers must be aware of these beliefs in
order to provide holistic care; that is, care that
provides for the well-being of the whole person
and meets not only physical needs, but also
social, emotional, and mental needs. Some areas
of cultural diversity include family organization,
language, personal space, touching, eye contact, FIGURE 9-4 An extended family includes grand-
gestures, health care beliefs, spirituality, and parents, aunts, uncles, and cousins in addition to
religion. the nuclear family.
262 CHAPTER 9
to take care of their children and sick or elderly ♦ Do you have extended family? For example,
relatives in their home. For example, most Asian aunts, uncles, cousins, nephews, nieces?
families have great respect for their elders and
consider it a privilege to care for them. In some
♦ Who will be caring for you while you are sick?
nuclear family cultures, people outside the fam- ♦ Who is the head of the household?
ily frequently care for children and sick or elderly ♦ Where do you and your family live?
relatives. Never assume anything about a family’s
♦ Was your entire family born in the United
organization. It is important to ask questions and
States?
observe the family.
Some families are patriarchal and the father ♦ What do you and your family do together for
or oldest male is the authority figure. In a matri- recreation?
archal family, the mother or oldest female is the ♦ Do you have family members who will be vis-
authority figure. This also affects health care. In a iting you? (If patient is admitted to a health
patriarchal family, the dominant male will make care facility)
most health care decisions for all family members.
For example, in some Asian and Middle Eastern
families, men have the power and authority, and
women are expected to be obedient. Husbands
LANGUAGE
frequently accompany their wives to medical In the United States, the dominant language
appointments and expect to make all the medical is English, but many other languages are
care decisions. In a matriarchal family, the domi- also spoken. Statistics from the U.S. Census
nant female may assume this responsibility. For Bureau verified that more than 20 percent of the
example, if the mother or other female is the dom- population younger than age 65 speaks a lan-
inant figure in a family, she will make the health guage other than English at home. There are even
decisions for all members of the family. In many variations within a language caused by different
families, both the mother and father share the dialects. For example, the German taught in
decisions. Regardless of who the decision maker school may differ from the language spoken by
is, respect for the individual and the family must Germans from different areas of Germany. Health
be the primary concern for the health care worker. care providers frequently encounter patients who
Health care providers must respect patients who do not use English as a dominant language. The
state, “I have to check with my husband (wife) health care provider must determine the patient’s
before I decide if I should have the surgery.” ability to communicate by talking with the patient
Recognition and acceptance of family orga- or a relative and asking questions such as:
nization is essential for health care providers.
Patients who have extended families as basic
♦ Do you speak English as your primary lan-
guage?
units may have many visitors in a hospital or
long-term care center. Everyone will be con- ♦ What language is spoken at home?
cerned with the care provided, and all family ♦ Do you read English? Do you read another
members may help make decisions regarding language?
care. At times, family members may even insist
on providing basic personal care to the patient,
♦ Do you have a family member or friend who
can interpret information for you?
such as bathing or hair care. Health care provid-
ers must adapt to these situations and allow the Whenever possible, try to find an interpreter
family to assist as much as possible. who speaks the language of the patient (figure
To determine a patient’s family structure 9-5). Frequently, another health care worker, a
and learn about a patient’s preferences, the consultant, or a family member may be able to
health care provider should talk with the patient assist in the communication process. Most health
or ask questions. Examples of questions that can care facilities have a roster of employees who
be asked include: speak other languages.
When providing care to people who have
♦ Who are the members of your family? limited English-speaking abilities, speak
♦ Do you have any children? Who will care for slowly, use simple words, use gestures or pictures
them while you are sick? to clarify the meaning of words, and use nonver-
PERSONAL SPACE
AND TOUCH
Personal space, often called territorial space,
describes the distance people require to feel com-
fortable while interacting with others. This varies
greatly among different ethnic/cultural groups.
Some cultures are called “close contact” and oth-
ers are called “distant contact.” Individuals from
close-contact cultures are comfortable standing
very close to and even touching the person with
whom they are interacting. For example, Arabs
are a very close-contact group; they touch, feel,
and smell people with whom they interact. French
and Latin Americans tend to stand very close
FIGURE 9-5 Whenever possible, try to find an together while talking. Hispanic Americans are
interpreter to assist in communicating with a non-
also comfortable with close contact and use hugs
English-speaking patient.
and handshakes to greet others. Even within a
cultural group, there are variations. For example,
women tend to stand closer together than men
do, and children stand closer together than adults
bal communication in the form of a smile or gen- do. European and African Americans prefer some
tle touch if it is culturally appropriate. Avoid the space (approximately 2–6 feet) during interac-
tendency to speak louder because this does not tions, but do not hesitate to shake hands as a
improve comprehension. Whenever possible, try greeting. Asian Americans will stand closer, but
to obtain feedback from the patient to determine usually do not touch during a conversation. Kiss-
whether the patient understands the information ing or hugging is reserved for intimate relation-
that has been provided. ships and is never done in public view. In
Most patients appreciate it when a health Cambodia, members of the opposite sex may
care worker can speak even a few words in the never touch each other in public, not even broth-
patient’s language. Make every attempt to try to ers and sisters. In addition, only a parent can
learn some words or phrases in the patient’s lan- touch the head of a child. The Vietnamese allow
guage. Even a few words allow you to show the only the elderly to touch the head of a child
patient that you are trying to communicate. If because the head is considered sacred. In some
you work with many patients who speak a com- Middle Eastern countries, men may not touch
mon language, such as Spanish, try to master the female individuals who are not immediate family
basics of that language by taking an introductory members, and only men may shake hands with
course or by using an audiotape. other men. This may cause a female from one of
Other resources are also available to help a these countries to refuse personal health care
health care provider meet the needs of a non- provided by a male health care provider. For
English-speaking patient. Many health care facil- Native Americans, personal space is important,
ities have health care information or questions but they will lightly touch another person’s hand
printed in several languages. Cards can be pur- during greetings. It is important to understand
chased that explain basic health care procedures that these situations are examples. You must
or treatments in many other languages. never assume anything about an individual’s per-
Most states require that any medical permit sonal space and touch preferences. You need to
requiring a written signature be printed in question the individual. Sample questions can be
the patient’s language to ensure that the patient found at the end of this section.
understands what he or she is signing. Health Health care providers have to use touch and
care providers must be aware of legal require- invade personal space to give many types of
ments for non-English-speaking patients and care. For example, taking blood pressure involves
make sure that these requirements are met. palpation of arteries, wrapping a cuff around a per-
264 CHAPTER 9
son’s arm, and placing a stethoscope on the skin. If regarding eye contact can lead to misunderstand-
a health care provider uses a slow, relaxed approach, ings when people of different cultures interact.
explains the procedure, and encourages the patient Health care providers must be alert to the com-
to relax, this may help alleviate fear and eliminate fort levels of patients while using direct eye contact
the discomfort and panic that can occur when per- and recognize the cultural diversity that exists. Lack
sonal space is invaded. Always be alert to the of eye contact is often interpreted as “not listen-
patient’s verbal and nonverbal communication, as ing,” when in reality, it can indicate respect.
well as inconsistencies between them. For exam-
ple, a patient may give verbal permission for a pro-
cedure, but may seem anxious when personal
space is invaded and demonstrate nonverbal
GESTURES
behavior such as tensing muscles, turning or pull- Gestures are used to communicate many things.
ing away, or shaking when touched. An alert health A common gesture in the United States is nod-
care provider can try to move away from the patient ding the head up and down for “yes,” and side to
periodically to give the patient “breathing room” side for “no.” In India, the head motions for “yes”
and encourage the patient to relax. and “no” are the exact opposite. Pointing at some-
When personal care must be provided to a one is also a common gesture in the United States
patient, the health care provider should and is frequently used to stress a specific idea. To
determine the patient’s preferences by talking Asian and Native Americans, this can represent a
with the patient or asking questions. Examples of strong threat. Even the hand gesture for “OK” can
questions may include: be found insulting to some Asians.
Again, health care providers must be aware of
♦ Do you prefer to do as much of your own per-
how patients respond to hand gestures. If a
sonal care as possible, or would you like assis-
patient seems uncomfortable with hand gestures,
tance?
they should be avoided.
♦ Would you like a family member to assist with
your personal care?
♦ Are there any special routines you would like HEALTH CARE BELIEFS
followed while receiving personal care?
♦ Do you prefer to bathe in the morning or eve- The most common health care system in
ning? the United States is the biomedical health
care system or the “Western” system. This system
♦ Is there anything I can do to make you more of health care bases the cause of disease on such
comfortable? things as microorganisms, diseased cells, and the
process of aging. When the cause of disease is
determined, heath care is directed toward elimi-
EYE CONTACT nating the microorganisms, conquering the dis-
ease process, and/or preventing the effects of
Eye contact is also affected by different cultural aging. Health care providers in the United States
beliefs. Most European Americans regard eye receive biomedical training and are licensed to
contact during a conversation as indicative of practice as professionals. Some beliefs of this sys-
interest and trustworthiness. They feel that indi- tem of care include encouraging patients to learn
viduals who look away are either not trustworthy as much as possible about their illnesses, inform-
or not paying attention. Some Asian Americans ing patients about terminal diseases, teaching
consider direct eye contact to be rude. Native self-care, using medications and technology to
Americans may use peripheral (side) vision and cure or decrease the effects of a disease or illness,
avoid direct eye contact. They may regard direct and teaching preventive care.
stares as hostile and threatening. Hispanic and Health care beliefs vary greatly. These beliefs
African Americans may use brief eye contact, but can affect an individual’s response to health care.
then look away to indicate respect and attentive- Most cultures have common conceptions regard-
ness. Muslim women may avoid eye contact as a ing the cause of illness, ways to maintain health,
sign of modesty. In India, people of different appropriate response to pain, and effective meth-
socioeconomic classes may avoid eye contact ods of treatment. Some of the common beliefs
with each other. The many different beliefs are shown in table 9-1. It is important to remem-
TABLE 9-1 Health Care Beliefs

TRADITIONAL METHODS OF RESPONSE TO
CULTURE HEALTH CONCEPTS CAUSE OF ILLNESS HEALERS TREATMENT PAIN
South Maintain harmony Supernatural cause Root doctor Restore harmony Tolerating pain
African of body, mind, and Spirits and demons Folk practi- Prayer or meditation is a sign of
spirit Punishment from tioners Herbs, roots, poultices, strength
Harmony with God (community and oils Some may
nature Conflict or “mother” Religious rituals express pain
Illness can be disharmony in life healer, Charms, talismans, and
prevented by diet, spiritualist) amulets
rest, and cleanli-
ness
Asian Health is a state of Imbalance between Herbalist Cold remedies if yang is Pain must be
physical and yin and yang Physician overpowering and hot accepted and
spiritual harmony Supernatural Shaman remedies if yin is endured
with nature forces such as healer overpowering silently
Balance of two God, evil spirits, (physician– Herbal remedies Displaying pain
energy forces: yin or ancestral priest) Acupuncture and in public
(cold) and yang spirits acupressure brings
(hot) Unhealthy environ- Energy to restore disgrace
ment balance between yin May refuse pain
and yang medication
European Health can be Outside sources Physician Medications and surgery Some express
maintained by such as germs, Nurse Diet and exercise pain loudly
diet, rest, and pollutants, or Home remedies and self- and emotion-
exercise contaminants care for minor illnesses ally
Immunizations and Punishment for Prayer and religious Others value
preventive sins rituals self-control in
practices help Lack of cleanliness response to
maintain health Self-abuse (drugs, pain
Good health is a alcohol, tobacco) Pain can be
personal responsi- helped by
bility medications
Hispanic Health is a reward Punishment from Native healers Hot and cold remedies to Many will
from God God for sins (Curandero, restore balance express pain
Health is good luck Susto (fright), mal Espiritual- Prayers, medals, verbally and
Balance between ojo (evil eye), or ista, Yerbero candles, and religious accept
“hot” and “cold” envidia (envy) or herbalist, rituals treatment
forces Imbalance between Brujo) Herbal remedies, Others feel pain
hot and cold especially teas is a part of life
Massage and must be
Anointing with oil endured
Wearing an Azabache
(black stone) to ward
off the evil eye
(continues)
266 CHAPTER 9
TABLE 9-1 Health Care Beliefs (continued)

TRADITIONAL METHODS OF RESPONSE TO
CULTURE HEALTH CONCEPTS CAUSE OF ILLNESS HEALERS TREATMENT PAIN
Middle Health is caused by Spiritual causes Traditional Meditation Tolerating pain

Eastern spiritual causes Punishment for healers Charms and amulets is a sign of
Cleanliness sins Physician Medications and surgery strength
essential for Evil spirits or evil Male health profession- Self-inflicted
health “eye” als prohibited from pain is used
Male individuals touching or examining as a sign of
dominate and female patients grief
make decisions on
health care
Native Health is harmony Supernatural Shaman Rituals, charms, and Pain is a normal
Ameri- between man and forces and evil Medicine Man masks part of life and
can nature spirits Prayer and meditation to tolerance of
Balance among Violation of a taboo restore harmony with pain signifies
body, mind, and Imbalance between nature strength and
spirit man and nature Plants and herbs power
Spiritual powers Medicine bag or bundle
control body’s filled with herbs and
harmony blessed by medicine
man
ber that not all individuals in a specific ethnic/ ♦ Energetic touch therapy: massage, acupunc-
cultural group will believe and follow all of the ture, acupressure, and therapeutic touch
customs. The customs, however, might still influ-
ence an individual’s response to a different type ♦ Body-movement methods: chiropractic, yoga,
of care. and tai chi
Health care providers must understand that ♦ Spiritual methods: faith healing, prayer, and
every culture has a system for health care based spiritual counseling
on values and beliefs that have existed for gener-
ations. Individuals may use herbal remedies, reli- It is important to remember that every indi-
gious rites, and other forms of ethnic/cultural vidual has the right to choose the type of
health care even while receiving biomedical health care system and method of treatment he
health care. A major change in the practice of or she feels is best. Health care providers must
health care in the United States is the increase in respect this right.
the use of alternative health care methods. Many To determine a patient’s health care prefer-
individuals are using alternative health care in ences the health care provider should talk
addition to, or as a replacement for, biomedical with the patient and ask questions. Examples of
care. Alternative health care providers include questions may include:
chiropractors, homeopaths, naturopaths, and ♦ What do you do to stay healthy?
hypnotists. Some types of treatments discussed
in more detail in table 1-8 of Chapter 1:2,
♦ Except for this current illness, do you feel that
you are reasonably healthy?
include:
♦ Nutritional methods: organic foods, herbs, ♦ What do you feel is a healthy diet? Do you try
to follow this diet?
vitamins, and antioxidants
♦ Mind and body control methods: relaxation, ♦ What do you do for exercise?
meditation, biofeedback, hypnotherapy, and ♦ Is there anything else that you do to stay
imagery healthy?
♦ Why do you think people become ill? spiritual beliefs are firmly established, the indi-
vidual has a basis for understanding life, finding
♦ What health care treatment method do you sources of support when they are needed, and
use when you are ill?
drawing on inner and/or external resources and
♦ Why do you think you have become ill? strength to deal with situations that arise. Spiritu-
♦ Were you born in the United States? Were your ality is often expressed through religious prac-
parents born in the United States? tices, but spirituality and religion are not the
same. Spirituality is an individualized and per-
♦ Do you or your parents still follow the tradi-
sonal set of beliefs and practices that evolves and
tions of your native land (or culture)? (If a
changes throughout an individual’s life.
patient and/or parents were not born in the
Religion is an organized system of belief in a
United States)
superhuman power or higher power. Religious
beliefs and practices are associated with a par-
SPIRITUALITY AND ticular form or place of worship. Beliefs about
birth, life, illness, and death usually have a reli-
RELIGION gious origin. Some of the more common religious
beliefs are shown in table 9-2. Religious beliefs
Spirituality and religion are an inherent part of that affect dietary practices are discussed in
every ethnic or cultural group. Spirituality is Chapter 11 in table 11-6.
defined as the beliefs individuals have about Even though a religion may establish certain
themselves, their connections with others, and beliefs and rituals, it is important to remember
their relationship with a higher power. It is also that not everyone follows all of the beliefs or
described as an individual’s need to find meaning rituals of their own religion. In addition, some
and purpose in life (figure 9-6). When a person’s individuals are non-believers. For example, an
atheist is a person who does not believe in any
deity. An agnostic is an individual who believes
that the existence of God cannot be proved or
disproved. Health care providers must determine
what an individual personally believes to be
important and respect that individual’s beliefs.
To determine an individual’s spiritual and
religious needs, the health care provider
should talk with the patient and ask questions.
Examples of questions that may be asked include:
♦ Do you have a religious affiliation?
♦ Are there any spiritual practices that help you
feel better (prayer, meditation, reading scrip-
tures)?
♦ Do you normally pray at certain times of the
day?
♦ Would you like a visit from a representative of
your religion?
♦ Do you consult a religious healer?
♦ Do you observe any special religious days?
♦ Do you wear clothing or jewelry with a reli-
gious significance?
♦ Do you have any religious objects that require
special care?
FIGURE 9-6 Spirituality is an individual’s need to ♦ Do your beliefs restrict any specific food or
find meaning and purpose in life. drink?
268 CHAPTER 9
TABLE 9-2 Major Religious Beliefs

BELIEFS ABOUT BELIEFS ABOUT SPECIAL SYMBOLS, BOOKS,
RELIGION BIRTH DEATH HEALTH CARE BELIEFS RELIGIOUS PRACTICES
Baptist No infant baptism Clergy provides prayer Oppose abortion Bible is holy book
(Christian)* Baptism after and counseling to Some believe in the Rite of Communion
person reaches patient and family healing power of important
age of under- Autopsy, organ “laying on of hands” Baptism by full immersion
standing donation, and May respond passively in water after a person
cremation are an to medical treatment, reaches an age of under-
individual’s choice believing that illness is standing and accepts
No last rites “God’s will” Jesus Christ
Physician is instrument Some use cross as symbol
for God’s intervention
Buddhism No infant baptism Believe in reincarna- Suffering is an inevitable Belief in Buddha, the
but have infant tion part of life “enlightened one”
presentation to Desire calm environ- Illness is the result of Tipitaka, three collections of
dedicate child to ment and limited negative Karma (a writings, are Buddhist
Buddha touching during the person’s acts and their canon
process of death ethical consequences) Nirvana, the state of greater
Buddhist priest must Cleanliness is important inner freedom, is the goal
be present at death to maintain health of existence
Last rites chanted at Emphasize practice and
bedside immediately personal enlightenment
after death rather than doctrine or
Autopsy and organ study of scripture
donation are con- May use pictures or statues
troversial but usually of Buddha as religious
regarded as an symbols
individual’s choice Some wear mala beads
Cremation is common around the left wrist that
may be removed only if
absolutely necessary
Christian No infant baptism No last rites Illness can be eliminated Bible is holy book
Scientist Autopsy only when through prayer and Rite of Communion
(Christian)* required by law spiritual understanding important
Organ donation May not use medicine or Science and Health by Mary
discouraged but can surgical procedures Baker Eddy is basic
be an individual’s May refuse blood textbook of Christian
decision transfusions Science
Will accept legally Prayer and faith will
mandated immuniza- maintain health and
tions prevent disease
Episcopal Infant baptism Some observe last May use Holy Unction or Bible is holy book
(Christian)* (may be per- rites by priest anointing of the sick Rite of Communion
formed by Autopsy and organ with oil as a healing important
anyone in an donation encouraged sacrament Book of Common Prayer
emergency) Cremation is an Use cross as symbol
individual’s choice
*Any religion that is designated as “Christian” has the following beliefs: (continues)
God is one in three parts: Father, Son, and Holy Spirit
Jesus Christ is the Son of God
By accepting Jesus Christ, a person may be saved and inherit eternal life
TABLE 9-2 Major Religious Beliefs (continued)

Hinduism No ritual at birth Believe in reincarna- Some believe illness is Vedas, four books, are the
Naming ceremony tion as humans, punishment for sins sacred scripture
is performed 10– animals, or even Some believe in faith Brahma is principal source
11 days after plants healing of universe and center of
birth to obtain Ultimate goal is Will accept most medical all things
blessings from freedom from the interventions All forms of nature and life
gods and cycle of rebirth and Abortion and birth are sacred
goddesses death control are discour- Person’s Karma is deter-
Priest ties thread aged mined by accumulated
around the neck or merits and demerits that
wrist of the deceased result from all the actions
and may pour water the soul has committed in
in the mouth its past life or lives
Only family and Cows are sacred and
friends may touch feeding a cow is an act of
and wash the body worship
Autopsy and organ May use symbols such as
donation discour- statues of various gods,
aged but regarded as flat stones, incense, or
individual’s decision sandalwood
Cremation preferred
Islam Believe that first Family must be with Illness is an atonement Allah is supreme deity
(Muslim) words an infant dying person for sins Mohammed, founder of
should hear at Dying person must May face city of Mecca Islam, is chief prophet
birth are “There confess sins and ask (southeast direction if Holy Day of Worship is
is no God but forgiveness in United States) five sunset Thursday to sunset
Allah, and Only family touches or times a day to pray to Friday
Mohammed is washes body after Allah Koran is holy book of Islam
His prophet.” death Ritual washing before (do not touch or place
Circumcision Body is turned toward and after prayer anything on top)
performed when Mecca after death Must take medications Prayer rug is sacred
7 days old Autopsy only when with right hand since Fast during daylight hours in
required by law left hand considered month of Ramadan and
Organ donation is dirty during other religious
permitted if donor holidays
consents in writing May wear item with words
Cremation not from Koran on arm, neck,
permitted or waist; do not remove or
allow item to get wet
An Imam is a Muslim
preacher and teacher
(continues)
270 CHAPTER 9

Jehovah’s No infant baptism No last rites Prohibited from receiv- Name for God is Jehovah
Witness Baptism by Autopsy only when ing blood or blood Bible is holy book: New
(Christian)* immersion done required by law and products World Bible
when child body parts may not Elders of church will Rite of Communion
accepts beliefs be removed pray and read scrip- important
Organ donation tures to promote Church elders provide
discouraged but healing guidance
decision is an Medications accepted if Each witness is a minister
individual’s choice not derived from blood who must spread the
All organs and tissues products group’s teachings
must be drained of Acknowledge allegiance only
blood before to kingdom of Jesus Christ
transplantation and refuse allegiance to
Cremation permitted any government
Judaism No infant baptism Person should never May refuse surgical Lord God Jehovah is one
(Orthodox) Male circumcision die alone procedure or diagnos- Sabbath is sunset Friday to
performed on Body is ritually tic tests on Sabbath or sunset Saturday
8th day after cleaned after death holy days Sabbath is devoted to
birth by Mohel May bury dead before Family may want prayer, study, and rest
(circumcisor), sundown on day of surgically removed Torah is basis of religion
child’s father, or death and usually body parts for burial (five books of Moses)
Jewish physician within 24 hours Ritual handwashing Rabbi is spiritual leader
Autopsy only when upon awakening and Cantor often leads prayer
required by law prior to eating services, performs
Organ donation only marriages, and conducts
after consultation funerals
with rabbi Star of David is symbol of
Cremation forbidden Judaism
Fast (no food or drink)
during some holy days
Men may wear kippah or
yarmulke (small cap) and a
tallith (prayer shawl)
Lutheran Infant baptism by No last rites Communion often Bible is holy book
(Christian)* sprinkling (may Autopsy and organ administered by clergy Rite of Communion
be performed by donation allowed to sick or prior to important
any baptized Cremation permitted surgery Use cross as symbol
Christian in an
emergency)
Methodist Infant baptism No last rites May request communion Bible is holy book
(United) Organ donations before surgery or while Rite of Communion
(Christian)* encouraged ill important
Cremation permitted Religion is a matter of
personal belief and
provides a guide for living
Use cross as symbol
(continues)

Mormon Infant blessed by May want church May believe in divine Mormon refers to the four
(Latter Day clergy in church elders present at healing with “laying on holy books: The Bible, The
Saints) as soon as death of hands” by church Book of Mormon, The
possible after No last rites elders Doctrine and Covenants,
birth Autopsy and organ Anointing with oil can and Pearl of Great Price
Baptism at 8 years donation is individu- promote healing Special undergarment may
of age al’s decision be worn to symbolize
Cremation discour- dedication to God and
aged should not be removed
unless necessary
Fast on first Sunday of each
month
Avoid medications contain-
ing alcohol or caffeine
Presbyterian Infant baptism No last rites Prayer and counseling Bible is holy book
(Christian)* Autopsy and organ an important part of Rite of Communion
donation permitted healing important
Cremation permitted May request communion Salvation is a gift from God
while ill or before Use cross as symbol
surgery
Roman Infant baptism Sacrament of the Sick Sacrament of the Sick Bible is holy book
Catholic mandatory (last rites) performed and anointing with oil Rite of Holy Eucharist (Com-
(Christian)* Baptism neces- by priest Life is sacred: abortion munion) important
sary for salvation Autopsy and organ and contraceptive use May use prayer books,
(any baptized donation permitted prohibited crucifix, rosary beads,
Christian may Cremation permitted Believe embryos are religious medals, pictures
perform an human beings and and statues of saints
emergency should not be Confession used as a rite for
baptism) destroyed or used for forgiveness of sins
research Use cross as symbol
Russian Infant baptism by Last rites by ordained Holy Unction and Bible is holy book
Orthodox priest priest mandatory anointing body with oil Rite of Communion
(Christian)* Arms of deceased are used for healing important
crossed Will accept most medical May wear a cross necklace
Autopsy only if treatments but believe that should not be
required by law in divine healing removed unless absolutely
Organ donations not necessary
encouraged Use cross as symbol
Cremation prohibited
Seventh Day No infant baptism No last rites May avoid over-the- Literal acceptance of Holy
Adventist (baptize individu- Autopsy only when counter medications Bible
(Christian)* als when they required by law and caffeine Rite of Communion
reach the age of Organ donation is an May anoint body with oil important
accountability) individual’s decision Use prayer for healing Sabbath worship is sunset
Some believe only in on Friday to sunset on
divine healing Saturday
Will accept required
immunizations
272 CHAPTER 9
behavior based on culture, ethnicity, race, life

experiences, spirituality, and religion. Even
though this pattern of behavior and beliefs may
change based on new exposures and experiences,
they are still an inherent part of the individual.
Health care workers must be aware of the
needs of each individual to provide total care.
They must learn to appreciate and respect the
personal characteristics of others. Some ways to
achieve this goal include:
♦ Listen to patients as they express their beliefs.
♦ Appreciate differences in people.
♦ Learn more about the cultural and ethnic
groups that you see frequently.
♦ Recognize and avoid bias, prejudice, and ste-
FIGURE 9-7 Always respect the patient’s religious reotyping.
symbols and books.
♦ Ask questions to determine a person’s beliefs.
♦ Evaluate all information before forming an
♦ Do you fast or abstain from eating certain opinion.
foods? ♦ Allow patients to practice and express their
♦ Should food be prepared in a certain way? beliefs as much as possible.
♦ Do you prefer certain types of foods (vegetar- ♦ Remember that you are not expected to adopt
ian diet, diet free from pork)? another’s beliefs, just accept and respect
them.
As long as it will not cause harm, every effort
must be made to allow an individual to express
♦ Recognize and promote the patient’s interac-
tions with family.
his or her beliefs, practice any rituals, and/or fol-
low a special diet. To show respect for an individ- ♦ Be sensitive to how patients respond to eye
ual’s beliefs and practices, the health care worker contact, touch, and invasion of personal
should: space.
♦ Be a willing listener. ♦ Respect spirituality, religious beliefs, symbols,
and rituals.
♦ Provide support for spiritual and religious
practices.
♦ Respect religious symbols and books (figure STUDENT: Go to the workbook and complete
the assignment sheet for Chapter 9, Cultural
9-7).
Diversity.
♦ Allow privacy for the patient during clergy vis-
its or while the patient is observing religious
customs such as communion, prayer, and
meditation.
♦ Refrain from imposing your own beliefs on the
CHAPTER 9 SUMMARY
patient.
Because health care providers work with and
care for many different people, they must be
9:4 INFORMATION aware of the factors that cause each individual
to be unique. These factors include culture, eth-
Respecting Cultural Diversity nicity, and race. Culture is defined as the values,
The key to respecting cultural diversity is to regard beliefs, attitudes, languages, symbols, rituals, be-
each person as a unique individual. Every indi- haviors, and customs unique to a group of peo-
vidual adopts beliefs and forms a pattern of ple and passed from one generation to the next.

A computer microchip that allows a physician to know what medication a person needs?
A major problem in health care today is determining what drug and what dosage should
be used for a patient. Individuals react to medications in different ways. Some individuals
need large amounts of pain medication; others need smaller quantities. A blood pressure
medication works well for one individual, but is not effective for another patient. An antibi-
otic cures an infection in one person but causes an allergic reaction that kills another per-
son. Pharmacogenetics, or prescribing medicine based on a person’s unique genetic makeup,
is the start of a revolution in personalizing treatment for a particular individual.
Researchers are using genetic information about individuals to try to determine their
reactions to different medications. Scientists have proved that there is a gene in a person’s
body that controls how a drug is absorbed, used, and eliminated. This gene may be different
from person to person. By learning an individual’s genetic makeup, a physician could pre-
scribe the exact medication and dosage that would be most beneficial to a patient.
Imagine a future where people will have a computer chip that contains all of their genetic
information. Before any medication is given to a patient, the genetic information will be
scanned to make sure it is compatible with the chemical properties of the medication. A
computer will analyze the information and determine the exact dosage needed by the
patient. Even though this process raises concerns about patient confidentiality, privacy, and
legal regulations, it has the potential to save lives. If a medicine given to a patient is based on
that person’s specific needs, diseases will be cured because they will be treated correctly.
Ethnicity is a classification of people based on Some areas of cultural diversity include family
national origin and/or culture. Race is a classifi- organization, language, personal space, touch-
cation of people based on physical or biological ing, eye contact, gestures, health care beliefs,
characteristics. The differences among people spirituality, and religion.
resulting from cultural, ethnic, and racial factors The key to respecting cultural diversity is to
are called cultural diversity. Health care provid- regard each person as a unique individual. Health
ers must show sensitivity, or recognize and ap- care providers must learn to appreciate and re-
preciate the personal characteristics of others, spect the personal characteristics of others.
because America is a multicultural society.
Bias, prejudice, and stereotyping can inter-
fere with acceptance of cultural diversity. A bias
is a preference that inhibits impartial judgment. INTERNET SEARCHES
A prejudice is a strong feeling or belief about a
person or subject that is formed without review- Use the suggested search engines in Chapter 12:4
ing facts or information. Stereotyping occurs of this textbook to search the Internet for addi-
when an assumption is made that everyone in a tional information on the following topics:
particular group is the same. Bias, prejudice, and
1. Cultural diversity: search words such as
stereotyping are barriers to effective relation-
culture, ethnicity, and race to obtain additional
ships with others. Health care providers must be
information on characteristics and examples
alert to these barriers and make every effort to
for each
avoid them.
An understanding of cultural diversity al- 2. Ethnic groups: search countries of origin for
lows health care providers to give holistic care; information on different ethic groups or on
that is, care that provides for the well-being of your own ethnic group; for example, if you are
the whole person and meets not only physical, German–Irish, search for information on both
but also social, emotional, and mental needs. Germany and Ireland
274 CHAPTER 9
3. Cultural assimilation and acculturation: search REVIEW QUESTIONS

for additional information on these two topics
4. Bias, prejudice, and stereotyping : use these key 1. Differentiate between culture, ethnicity, and
words to search for more detailed information race.
5. Family structure: search words such as 2. Name five (5) common ethnic groups and at
extended or nuclear family, patriarchal, and/or least two (2) countries of origin for each group.
matriarchal
3. Create examples of how a bias, prejudice, and
6. Health care beliefs: search by country of origin stereotype may interfere with providing quality
for health care beliefs, or search words such as health care.
yin and yang or shaman
4. Describe your family structure. Is it a nuclear
7. Alternative health care: search for additional or extended family? Is it patriarchal or matriar-
information on chiropractor, homeopath, chal or neither? Why?
naturopath, hypnotist, hypnotherapy, medita-
tion, biofeedback, acupuncture, acupressure, 5. Do you feel acculturation occurs in the United
therapeutic touch, yoga, tai chi, and/or faith States? Why or why not?
healing 6. Describe at least three (3) different health care
8. Spirituality and religion: search for additional practices that you have seen or heard about.
information on spirituality; use the name of a Do you feel they are beneficial or harmful?
religion to obtain more information about the Why?
beliefs and practices of the religion 7. Differentiate between spirituality and religion.
8. List six (6) specific ways to respect cultural
diversity.
NOTE: The cultural assessment questions presented
in this unit were adapted from Joan Luckmann’s
Transcultural Communication in Health Care,
which adapted them from Fong’s CONFHER model
and Rosenbaum.
CHAPTER 10 Geriatric Care
Chapter Objectives
Observe Standard
Precautions
◆ Differentiate between the myths and facts of
six aspects of aging
◆ Identify at least two physical changes of aging
in each body system
◆ Demonstrate at least ten methods of providing
care to the elderly individual who is
Caution
experiencing physical changes of aging
◆ List five factors that cause psychosocial
changes of aging
on Federal Law ◆ Describe at least six methods to assist an
elderly individual in adjusting to psychosocial
changes
Math Skill
◆ Recognize the causes and effects of confusion
and disorientation in the elderly
◆ Create a reality orientation program
Science Skill
◆ Justify the importance of respecting cultural
and religious differences
◆ Explain the role of an ombudsman
Career Information
Technology
276 CHAPTER 10
KEY TERMS
Alzheimer’s disease (AD) dementia (d-men⬘-she-a) ombudsman
(Altz⬘-high-merz⬙) disability osteoporosis
arteriosclerosis disease (os-tee⬘-oh-pour-oh⬘-sis)
(r-tear-ee-o-skleh-row⬘-sis) dysphagia (dis-fay⬘-gee-ah) reality orientation (RO)
arthritis emphysema religion
atherosclerosis (ath-eh-row⬙- geriatric care senile lentigines
skleh-row⬘-sis) gerontology (seen⬘-ile len-ti⬘-jeans)
bronchitis (jer-un-tahl⬘-oh-gee) thrombus
cataracts glaucoma (glaw-ko⬘-mah) transient ischemic attacks
cerebrovascular accident incontinence (TIAs)
culture myths (tran⬘-z-ent is-ke⬘mik)
delirium nocturia (nok-tur⬘-ee-ah)
INTRODUCTION 10:1 INFORMATION

Just as they experienced the “baby boom,” the Myths on Aging
United States and most other countries are now
experiencing an “aging boom.” In 1900, most Aging is a process that begins at birth and ends at
individuals died before age 60, and there were death. It is a normal process and leads to normal
only 3.1 million people older than 65 in the United changes in body structure and function. Even
States. In 2000, there were 34.7 million people though few people want to grow old, it is a natu-
older than 65 and 4.2 million people older than ral event in everyone’s life. Gerontology is the
85 years in the United States. U.S. government scientific study of aging and the problems of the
statistics prepared by the National Council on old. Geriatric care is care provided to elderly
Aging project that by 2010, 40.2 million Ameri- individuals. Through the study of the aging pro-
cans will be older than 65 and 5.7 million will be cess and the elderly, many facts on aging have
older than 85. By 2020, 54.6 million Americans been established. However, many myths, or false
will be older than 65 and 7.3 million will be older beliefs, still exist regarding aging and elderly indi-
than 85. By 2030, projections estimate that there viduals. It is essential for the health care worker
will be 70.3 million people older than 65, includ- to be able to distinguish fact from myth when
ing 8 million older than 85, in the United States. providing geriatric care.
In addition, by 2030, the National Council on
Aging predicts that almost 20 percent of the total ♦ Myth: Most elderly individuals are cared for in
population in the United States will be older than institutions or long-term care facilities.
65. These statistics truly indicate an “aging ♦ Fact: Only approximately 5 percent of the
boom.” elderly population lives in long-term care
Today, most individuals can expect to live facilities. Most elderly individuals live in their
into their 70s, and many individuals enjoy healthy own homes or apartments, or with other fam-
and happy lives as 80- and 90-year-olds. This age ily members (figure 10-1). Others may choose
group uses health care services frequently, so it is to live in retirement communities or in inde-
essential for a health care worker to understand pendent-living or assisted-living facilities.
the special needs of the elderly population. These facilities provide assistance with meals,
Geriatric Care 277
♦ Myth: All elderly people live in poverty.

♦ Fact: Recent statistics provided by the U.S.
government show that less than 10 percent of
adults older than 65 live at the poverty level.
Even though many older individuals have lim-
ited incomes, most also have comparatively
low expenses. Many own their own homes,
and their children are raised and out on their
own. With social security, savings, retirement
pensions, and other sources of income, some
elderly individuals are financially secure and
enjoy comfortable lifestyles. Although it is true
that some elderly individuals live in poverty,
this is true of some individuals in all age
FIGURE 10-1 Most elderly individuals live in their
own homes or apartments.
groups. The financial status of the elderly var-
ies just as the financial status of young or
transportation, housekeeping, social activi- middle-aged people varies.
ties, and medical care. By purchasing or rent- ♦ Myth: Older people are unhappy and lonely.
ing a home or apartment in one of these ♦ Fact: Studies have shown that most elderly
facilities, the individual can obtain the degree individuals live with someone and/or associate
of assistance needed while still living inde- frequently with friends or family members.
pendently. Many elderly individuals are active in civic
♦ Myth: Anyone over a certain set age, such as groups, charities, social activities, and volun-
65, is “old.” teer programs. Others provide care for grand-
♦ Fact: Old is determined less by the number of children and remain active as heads of extended
years lived and more by how an individual families (figure 10-2). Although it is true that
thinks, feels, and behaves. For example, to a some elderly individuals are lonely and
10-year-old, a 35-year-old is old. It is impor- unhappy, the percentage is small, and many
tant to remember that many individuals are social agencies exist to assist these individuals.
active, productive, and self-sufficient into ♦ Myth: Elderly individuals do not want to
their 80s and even 90s. Too often the term old work—that is, the goal of the elderly is to retire
becomes synonymous with worthless or worn- and, prior to retirement, they lose interest in
out. A better term would be experienced or work.
mature. ♦ Fact: Many individuals remain employed and
♦ Myth: Elderly people are incompetent and productive into their 70s and even 80s (figure
incapable of making decisions or handling 10-3). Studies have shown that the older
their own affairs. worker has good attendance, performs effi-
♦ Fact: Even though some experience confusion ciently, readily learns new skills, and shows
and disorientation, the majority of elderly job satisfaction. Employers, desiring good
individuals remain mentally competent until work ethics and experience, frequently recruit
they die. In fact, older individuals may make and hire older workers. In addition, if projec-
better decisions and judgments because they tions from the National Council on Aging
frequently base their decisions on many years prove accurate, by 2030, one of every five
of experience and knowledge. In addition, people in the United States will be older than
studies have proved that older people are able 65. Employers will have to rely on older work-
to concentrate, learn new skills, and evaluate ers to fill job vacancies. Many retired individu-
new information. Colleges and adult educa- als do not want a full-time job, but they return
tion programs recognize this fact and often to part-time positions or serve as consultants
provide tuition-free access that allows elderly or volunteer workers.
individuals to participate in a wide variety of ♦ Myth: Retired people are bored and have noth-
educational programs. ing to do with their lives.
278 CHAPTER 10
Many other myths also exist. It is important

for the health care worker both to recognize prob-
lems that do exist for the elderly and to under-
stand that the needs of the elderly vary according
to many circumstances. Even the fact that only 5
percent of the elderly are in long-term care facili-
ties means that more than 3 million people will
be in these facilities by the year 2020. Many health
care workers at all levels will provide needed ser-
vices for these individuals. Geriatric care is and
will continue to be a major aspect of health care.

the assignment sheet for 10:1, Myths on Aging.
10:2 INFORMATION
Physical Changes of Aging
As aging occurs, certain physical changes also
occur in all individuals (figure 10-4). These
changes are a normal part of the aging process. It
is important to note that most of the changes are
gradual and take place over a long period. In
addition, the rate and degree of change varies
FIGURE 10-2 Caring for grandchildren is a very among individuals. Factors such as disease can
satisfying social relationship for many elderly increase the speed and degree of the changes.
individuals. Lifestyle, nutrition, economic status, social envi-
ronment, and limited access to medical care can
also have effects.
Most physical changes of aging involve a
decrease in the function of body systems. Body
processes slow down. There is a corresponding
decrease in energy level. If an individual can rec-
ognize these changes as a normal part of aging,
FIGURE 10-3 Many individuals remain employed

and productive into their 70s and even 80s.
♦ Fact: Many retired people enjoy full and active

lives. They engage in travel, hobbies, sports,
social activities, family events, and church or
community activities. In fact, many retired
individuals say, “I don’t know how I found
time to work.” FIGURE 10-4 Note the physical signs of aging.
Geriatric Care 279
the individual can usually learn to adapt to and Good skin, nail, and hair care are essential.
cope with the changes. Mild soaps should be used because many soaps
cause dryness. Frequently, bath oils or moistur-
izing lotions are recommended to combat dry-
INTEGUMENTARY ness and itching. Daily baths can also contribute
SYSTEM to dry, itchy skin; baths or showers two or three
times a week with partial baths on other days are
Some of the most obvious effects of aging are recommended. Brushing of the hair helps stimu-
seen in the integumentary system (figure 10-5). late circulation and production of oil. Shampoo-
Production of new skin cells decreases with age. ing is usually done less frequently, but should be
The sebaceous (oil) and sudoriferous (sweat) done as often as needed for cleanliness and com-
glands become less active. Circulation to the skin fort. Any sores or injuries to the skin should be
decreases and causes coldness, dryness, and poor cared for immediately. It is important to keep
healing of injured tissue. The hair loses color, and injured areas clean and free from infection. When
hair loss occurs. elderly people notice sores or injuries that do not
The decreases in body function lead to the heal, they should get medical help. Frequently,
physical changes. The skin becomes less elastic the elderly person requires a room temperature
and dry. Itching is common. Dark yellow or brown that is higher than normal and free from drafts.
colored spots, called senile lentigines, appear. Socks, sweaters, lap blankets, and layers of cloth-
Although these are frequently called “liver spots,” ing can all help alleviate the feeling of coldness.
they are not related to the liver. When the fatty The use of hot water bottles or heating pads is not
tissue layer of the skin diminishes, lines and recommended because the decreased sensitivity
wrinkles develop. The nails become thick, tough, to temperature can result in burns.
and brittle. An increased sensitivity to tempera- Proper diet, exercise, good hygiene, decreased
ture develops, and the elderly adult frequently sun exposure, and careful skin care can help slow
feels cold. Hypothermia, a below normal body and even decrease the normal physical changes
temperature, can be a serious problem for the in the integumentary system.
elderly.
MUSCULOSKELETAL
SYSTEM
As aging occurs, muscles lose tone, volume, and
strength. Osteoporosis, a condition in which
calcium and other minerals are lost from the
bones, causes the bones to become brittle and
more likely to fracture or break. Arthritis, an
inflammation of the joints, causes the joints to
become stiff, less flexible, and painful. The rib
cage becomes more rigid, and the bones in the
vertebral column press closer together (com-
press).
These changes cause the elderly individual to
experience a gradual loss in height, decreased
mobility, and weakness. Movement is slower, and
the sense of balance is less sure. Falls occur easily
and often result in fractures of the hips, arms,
and/or legs. Fine finger movements, such as those
required when buttoning clothes or tying shoes,
are often difficult for the elderly individual.
FIGURE 10-5 Some of the most obvious effects Elderly individuals should be encouraged to
of aging are seen on the skin. exercise as much as their physical conditions
280 CHAPTER 10
permit (figure 10-6). This helps keep muscles

active and joints as flexible as possible. Even slow, CIRCULATORY SYSTEM
daily walks help maintain muscle tone. Range-of-
In the circulatory system, the heart muscle
motion exercises can also maintain muscle
becomes less efficient at pushing blood into the
strength. A diet rich in protein, calcium, and vita-
arteries, and cardiac output decreases with aging.
mins can slow the loss of minerals from the bones
The blood vessels narrow and become less elas-
and maintain muscle structure. Extra attention
tic. Blood flow to the brain and other vital organs
must be paid to the environment so it is safer for
may decrease. Blood pressure may increase or
the elderly person. Grab bars in the bathroom,
decrease.
hand rails in halls and on stairs, and other similar
Many elderly individuals do not notice any
devices aid in ambulation. When the sense of bal-
changes while at rest. They are more aware of
ance is poor, an elderly person may need assis-
changes when exercise, stress, excitement, ill-
tance and support during ambulation. The use of
ness, and other similar events call for increases in
walkers and quad canes is frequently recom-
the body’s need for oxygen and nutrients. During
mended. In addition, well-fitting shoes with non-
these periods, they experience weakness, dizzi-
slip soles and flat heels can help prevent falls.
ness, numbness in the hands and/or feet, and a
Self-stick strips and bands can replace buttons
rapid heart rate.
and shoestrings to make dressing easier. A con-
Elderly individuals who experience circula-
sultation with a physician, physical therapist,
tory changes should avoid strenuous exercise or
and/or occupational therapist can provide an
overexertion. They need periods of rest during
elderly individual with information on the latest
the day. Moderate exercise, according to the indi-
and most effective adaptive devices to maintain
vidual’s ability to tolerate it, does stimulate circu-
independence.
lation and help prevent the formation of a
thrombus, or blood clot. Support stockings,
antiembolism hose, and not using garters or
tight bands around the legs also help prevent
blood clots. If an individual is confined to bed,
range-of-motion exercises help circulation. If
high blood pressure is present, a diet low in salt
or sodium and, in some cases, fat may be recom-
mended. Individuals with circulatory system dis-
ease should follow the diet and exercise plans
recommended by their doctors.
RESPIRATORY SYSTEM
Respiratory muscles become weaker with age.
The rib cage becomes more rigid. The alveoli, or
air sacs in the lungs, become thinner and less
elastic, which decreases the exchange of gases
between the lungs and bloodstream. The bron-
chioles, or air tubes in the lungs, also lose elastic-
ity. Changes in the larynx lead to a higher-pitched
and weaker voice. Chronic conditions such as
emphysema, in which the alveoli lose their elas-
ticity, or bronchitis, in which the bronchioles
become inflamed, decrease the efficiency of the
respiratory system even more severely.
FIGURE 10-6 Elderly individuals should be These changes frequently cause the elderly
encouraged to exercise as much as their physical individual to experience dyspnea, or difficult
condition permits. breathing. Breathing becomes more rapid, and
Geriatric Care 281
they have difficulty coughing up secretions from

the lungs. This makes them more susceptible to
respiratory infections such as colds and pneu-
monia.
Learning to alternate activity with periods
of rest is important to avoid dyspnea. Proper
body alignment and positioning can also ease
breathing difficulties. The elderly individual with
respiratory problems frequently sleeps in a semi-
Fowler’s position with two or three pillows elevat-
ing the upper body to make breathing easier.
Avoiding polluted air, such as that in smoke-filled
rooms, is essential. Breathing deeply and cough-
ing at frequent intervals helps clear the lung
passages and increase lung capacity. Elderly indi-
viduals with chronic respiratory problems often
use oxygen on a continuous basis. Portable oxy-
gen units allow many individuals to continue to
lead active lives.
NERVOUS SYSTEM
FIGURE 10-7 Individuals who remain mentally
Physical changes in the nervous system affect active usually show fewer mental changes.
many body functions. Blood flow to the brain
decreases, and there is a progressive loss of brain
cells. This interferes with thinking, reacting, inter- interferes with vision, is also more common in
preting, and remembering. The senses of taste, the elderly. Proper eye care, prescription glasses/
smell, vision, and hearing diminish. Nerve end- lenses, medical treatment of cataract or glau-
ings are less sensitive, and there is a decreased coma, and proper lighting can all improve vision
ability to respond to pain and other stimuli. (figure 10-8).
As these physical changes occur, the elderly Hearing loss usually occurs gradually in the
individual may experience memory loss. Short- elderly. The individual may speak more loudly
term memory is usually affected. For example, an than usual, ask for words to be repeated, and not
individual may not remember what he or she ate hear high-frequency sounds such as the ringing
for breakfast, but does remember the entire menu of a telephone. Problems may be more apparent
from his or her retirement party. Long-term when there is a lot of background noise. For
memory and intelligence do not always decrease. example, an elderly person may not hear well in a
It may take elderly individuals longer to react, but crowded restaurant where music is playing and
given enough time, they can think and react many other people are talking. A hearing aid can
appropriately. Individuals who remain mentally help resolve some hearing problems. However, in
active and involved in current events usually cases of severe nerve damage, a hearing aid will
show fewer mental changes (figure 10-7). not eliminate the problem. In addition, many
Changes in vision cause problems in reading individuals resist using hearing aids. If a person
small print or seeing objects at a distance. There wears a hearing aid, it is important to keep the
is a decrease in peripheral (side) vision and night aid in good working condition by changing bat-
vision. The eyes take longer to adjust from light to teries, keeping the aid clean, and checking to
dark, and there is an increased sensitivity to glare. make sure the individual is wearing it correctly.
Elderly individuals are also more prone to the When a person has a hearing impairment, it is
development of cataracts, where the normally important to talk slowly and clearly. Avoid yelling
transparent lens of the eye becomes cloudy or or speaking excessively loud. Facing individuals
opaque. Glaucoma, a condition in which the while talking to them also helps in many situa-
intraocular pressure of the eye increases and tions. Eliminating background noise, such as that
282 CHAPTER 10
FIGURE 10-8 Good lighting and large numbers

on a telephone can help improve vision. FIGURE 10-9 Elderly individuals may want to add
salt to food because of their decreased sense of
produced by a radio or television, also increases taste.
the ability to hear.
The decrease in the sense of taste and smell the changes become severe. For example, many
frequently affects the appetite. Elderly individu- elderly individuals continue to drive cars. Because
als often complain that food is tasteless and add of slower reaction times, however, these individ-
sugar, salt, or pepper (figure 10-9). Attractive uals may be more prone to having automobile
foods with a variety of textures and tastes may accidents. When an elderly person shows
help stimulate the appetite. The decrease in the impaired driving ability, it often becomes neces-
sense of smell may also make the elderly individ- sary for a family member or the law to prevent
ual less sensitive to the smell of gas, chemicals, the individual from driving.
smoke, and other dangerous odors. A smoke
detector, chemical detectors, and careful moni-
toring of the environment can help eliminate this
danger.
DIGESTIVE SYSTEM
Decreased sensation of pain and other stim- Physical changes in the digestive system occur
uli can lead to injuries. The elderly are more sus- when fewer digestive juices and enzymes are pro-
ceptible to burns, frostbite, cuts, fractures, muscle duced, muscle action becomes slower and peri-
strain, and many other injuries. At times, elderly stalsis decreases, teeth are lost, and liver function
people are not even aware of injury or disease decreases.
because they do not sense pain. It is important Dysphagia, or difficult swallowing, is a fre-
for elderly individuals to handle hot or cold items quent complaint of the elderly. Less saliva and a
with extreme care, and to be aware of dangers in slower gag reflex contribute to this problem. In
the environment. addition, the loss of teeth or use of poor-fitting
Changes in the nervous system usually occur dentures makes it more difficult to chew food
gradually over a long period of time. This allows properly. Another common complaint is indiges-
an individual time to adapt to the changes and tion, which results from slower digestion of foods
learn to accommodate them. However, it is some- caused by decreased digestive juices. Flatulence
times necessary for someone else to assist when (gas) and constipation are common because of
Geriatric Care 283
decreased peristalsis and poor diet. The decreased capacity and lead to more control over urination
sensation of taste also contributes to a poor appe- in incontinent persons. An indwelling catheter
tite and diet. may be needed if all urinary control is lost.
Good oral hygiene, repair or replacement of When changes in the urinary system cause
damaged teeth, and a relaxed eating atmosphere poor functioning of the kidneys, waste substances
can contribute to better chewing and digestion of can build up in the bloodstream and cause seri-
food. Most elderly people find it is best to avoid ous illness. Therefore, it is important to keep the
dry, fried, and/or fatty foods because such foods kidneys functioning as efficiently as possible.
are difficult to chew and digest. High-fiber and
high-protein foods with different tastes and tex-
tures are recommended. Careful use of season- ENDOCRINE SYSTEM
ings and herbs to improve taste also increases
appetite. It is important to avoid excessive sea- Changes in the endocrine system result in
sonings because they can cause indigestion. increased production of some hormones, such
Increasing fluid intake makes swallowing easier, as parathormone and thyroid-stimulating hor-
helps prevent constipation, and aids kidney func- mone, and decreased production of other hor-
tion. mones, such as thyroxin, estrogen, progesterone,
and insulin. The actions of these hormones are
listed in Chapter 7:13 of this text.
URINARY SYSTEM Because hormones affect many body func-
tions, several physical changes may occur. The
With aging, the kidneys decrease in size and immune system of the body is less effective, and
become less efficient at producing urine. Poor elderly individuals are more prone to disease. The
circulation to the kidneys and a decrease in the basal metabolic rate decreases, resulting in com-
number of nephrons result in a loss of ability to plaints of feeling cold, tired, and less alert (figure
concentrate the urine, which causes a loss of 10-10). Intolerance to glucose can develop, result-
electrolytes and fluids. The ability of the bladder ing in increased blood glucose levels.
to hold urine decreases. Sometimes the bladder As with the other body systems, changes in
does not empty completely and urine is retained the endocrine system occur slowly over a long
in the bladder, a major cause of bladder infec- period of time. Many elderly individuals are not
tions. as aware of changes in this system. Proper exer-
The elderly person may find it necessary to cise, adequate rest, medical care for illness, a
urinate more frequently. Nocturia, or urination
at night, is common and disrupts the sleep pat-
tern. Retention of urine in the bladder causes
bladder infections. Men frequently experience
enlargement of the prostate gland, which makes
urination difficult and causes urinary retention.
Loss of muscle tone results in incontinence, or
the inability to control urination. Incontinence
may also result from treatment for prostatic
hypertrophy (enlargement) or cancer.
Many elderly individuals decrease fluid intake
to cut down on the frequent need to urinate. This
can cause dehydration, kidney disease, and infec-
tion. Elderly individuals should be encouraged to
increase fluid intake to improve kidney function.
To decrease incidents of nocturia, most fluids
should be taken before evening. Regular trips to
the bathroom, wearing easy-to-remove clothing,
and using absorbent pads as needed can help the
individual who has mild incontinence. Bladder FIGURE 10-10 A lap blanket can help when an
training programs can also help increase bladder elderly person complains of feeling cold.
284 CHAPTER 10
balanced diet, and a healthy lifestyle all help

decrease the effects caused by changes in hor-
mone activity.
REPRODUCTIVE SYSTEM
In the reproductive system, the decrease of estro-
gen and progesterone in women causes a thin-
ning of the vaginal walls and a decrease in vaginal
secretions. Vaginal infections or inflammations
become more common. In some cases, a weak-
ness in its supporting tissues causes the uterus to
sag downward, a condition known as prolapsed
uterus. The breasts sag when fat is redistributed.
Slowly decreasing levels of testosterone in
men slow the production of sperm. Response to
sexual stimulation of the penis is slower, and FIGURE 10-12 To respect the right to privacy,
ejaculation may take longer. The testes become always knock before entering a resident’s room.
smaller and less firm. The seminal fluid becomes
thinner, and smaller amounts are produced.
Sexual desire and need do not necessarily
diminish with age (figure 10-11). Many elderly
individuals are sexually active. Studies have
shown that sex improves muscle tone and cir-
culation. Even pain from arthritis seems to SUMMARY
decrease after sexual activity, probably because Aging causes many physical changes in all body
of increased hormone levels. When elderly indi- systems. The rate and degree of the changes vary
viduals are in long-term care facilities, it is impor- in different individuals, but all elderly individuals
tant for the health care worker to understand experience some degree of change. Providing
both the physical and psychological sexual needs means of adapting to and coping with changes
of the resident. Long-term care facilities now allows elderly people to enjoy life even with phys-
allow married couples to live together in the same ical limitations. It is important for all health care
room. The health care worker must respect the workers to learn to recognize changes and pro-
privacy of these residents and allow them to meet vide methods for dealing with them. Tolerance,
their sexual needs (figure 10-12). patience, and empathy are essential.

the assignment sheet for 10:2, Physical Changes of
Aging.
10:3 INFORMATION
Psychosocial Changes of Aging
In addition to physical changes, elderly individu-
als also experience psychological and social
changes. Some individuals cope with these
changes effectively, but others experience
extreme frustration and mental distress. It is
important for the health care worker to be aware
FIGURE 10-11 Elderly individuals still experience of the psychosocial changes and stresses experi-
a need for companionship and sexuality. enced by the elderly.
Geriatric Care 285
WORK AND
RETIREMENT
Most adults spend a large portion of their days
working. Many associate their feelings of self-
worth with the jobs they perform. They are proud
to state that they are nurses, electricians, teach-
ers, lawyers, or secretaries. In addition, social
contact while working is a major form of interac-
tion with others.
Retirement is often viewed as an end to the FIGURE 10-13 After the death of a spouse, the
working years. Many individuals are able to enjoy elderly individual sometimes may adjust by making
retirement and find other activities to replace job new social contacts.
roles. Some individuals find part-time or consul-
tant-type jobs after retirement from their primary social events and isolate themselves from others.
jobs. Other individuals become active in volun- The death of a spouse is frequently devastating to
teer work or take part in community or club an elderly individual, especially when a couple
activities. These individuals find satisfactory has had a close relationship for many years. A
replacements for the feelings of self-worth once surviving spouse may even attempt suicide. Psy-
provided by their jobs. chological help is essential in these cases.
However, some elderly individuals feel a
major sense of loss upon retirement. They lose
social contacts, develop feelings of uselessness, LIVING ENVIRONMENTS
and in some cases, experience financial difficul-
ties. This causes them to experience stress, and Changes in living environments create psychoso-
they frequently become depressed. Until other cial changes. Most elderly individuals prefer to
sources of restoring the individual’s sense of self- remain in their own homes. They feel secure sur-
worth are found, these elderly individuals can rounded by familiar environments. Many elderly
have difficulty coping with life. individuals express fear at the thought of losing
their homes.
Some elderly people leave their homes by
SOCIAL RELATIONSHIPS personal choice. They find the burden of main-
taining their homes too great and move to apart-
Social relationships change throughout life. ments or retirement communities. The elderly
Among the elderly, these changes may occur individual may even move to another state with a
more frequently. Often, children marry and move better climate. These individuals often cope well
away. This brings about a loss of contact with the with the change in living environment and feel
family. If a spouse dies, the “couple” image is the change is beneficial.
replaced by one of “widow” or “widower.” As a Financial problems or physical disabilities
person ages, more friends and relatives die, and may force some people to move from their homes,
social contacts decrease. sometimes to retirement communities or apart-
Some elderly individuals are able to adjust to ments. If they can maintain their independence,
these changes by making new friends and estab- coping is usually good. In other cases, an elderly
lishing new social contacts (figure 10-13). Church individual may be forced to move in with a son or
and community groups provide many social daughter. This move creates a change in roles,
activities for the elderly. By taking part in these where the child becomes the caretaker of the par-
activities, individuals who made friends readily ent. If the elderly person feels secure in this situ-
throughout their lives can continue to do so as ation, coping occurs. However, if the elderly
they grow older. person feels unwanted or useless, conflicts and
Some elderly individuals cannot cope with tension may develop.
the continuous loss of friends and relatives. They Moving to a long-term care facility often cre-
become withdrawn and depressed. They avoid ates stress in elderly individuals. They feel a loss
286 CHAPTER 10
of independence and become frightened by their have to depend on others to take them where
lack of control over environment. Many elderly they need to go. Physical limitations prevent
individuals view long-term care facilities as them from mowing lawns, cooking meals, wash-
“places to die,” even when they may require the ing, cleaning, and in some cases, even taking care
use of the facility for only a short period. For this of themselves. Frustration, anger, and depression
reason, it is important to allow individuals to cre- can develop.
ate their own “home” environments in the facility Any care provided to elderly individuals
(figure 10-14). Most long-term care facilities refer should allow as much independence as possible.
to the individuals as “residents.” They allow the Assistance should be provided as needed for the
residents to bring favorite pieces of furniture, individual’s safety, but the individual should be
pictures, televisions, radios, and personal items. allowed to do as much as possible. For example, a
By being allowed choices in the arrangement of health care worker should encourage elderly per-
their items, residents are able to create comfort- sons to choose their clothing and dress them-
able, homelike environments. Factors such as selves, even if this takes longer (figure 10-15).
these allow the elderly individual to adjust to the Self-stick strips can replace buttons to make the
new environment and to cope with the changes it task of dressing easier and to provide more inde-
brings. pendence. This helps the elderly individual adapt
to the situation and maintain a sense of self-
worth. At all times, elderly individuals should be
INDEPENDENCE allowed as much choice as possible to help them
maintain their individuality.
Most individuals want to be independent and
self-sufficient. Even 2-year-olds begin to assert
their right to choose and strive to be indepen-
dent. Just as children learn that there are limits to
DISEASE AND
independence, the elderly learn that indepen- DISABILITY
dence can be threatened with age. Physical dis-
ability, illness, decreased mental ability, and other Elderly people are more prone to disease and dis-
factors can all lead to a loss of independence in ability. Disease is usually defined as any condi-
the elderly. tion that interferes with the normal function of
Individuals who once took care of themselves the body. Common examples in the elderly
find it necessary to ask others for assistance. After include diabetes, heart disease, emphysema,
driving for a lifetime, elderly individuals might
find that they can no longer drive safely. They
FIGURE 10-14 It is important to allow residents FIGURE 10-15 To promote independence,

to create their own “home” environments in the long- encourage elderly individuals to make as many
term care facility. decisions as possible.
Geriatric Care 287
arthritis, and osteoporosis. A disability is

defined as a physical or mental defect or handi- SUMMARY
cap that interferes with normal functions. Hear-
Psychosocial changes can be major sources of
ing impairments, visual defects, or the inability
stress in the elderly. As changes occur, the indi-
to walk caused by a fractured hip are examples.
vidual must learn to accommodate the changes
Diseases sometimes cause permanent disabili-
and function in new situations. It is important to
ties. For example, a cerebrovascular accident, or
remember that older adults have survived many
stroke, can result in permanent paralysis of one
crises in their lives and have learned many differ-
side of the body, or hemiplegia.
ent coping methods. These individuals must be
When disease or disability affects the func-
encouraged to use their existing strengths and
tioning of the body, an individual may experience
coping skills. With support, understanding, and
psychological problems. When this occurs in an
patience, the health care worker can assist elderly
elderly individual already stressed by other
individuals as they learn to adapt.
changes or circumstances, it can be traumatic. A
fractured hip can cause an elderly individual who
had been living independently in his or her own
the assignment sheet for 10:3, Psychosocial
home to be admitted to a long-term care facility.
Changes of Aging.
Disease or disability frequently occurs suddenly
and does not allow for gradual adjustment to and
coping with change. 10:4 INFORMATION
Sick people often have fears of death, chronic
illness, loss of function, and pain. These are nor- Confusion and Disorientation
mal fears, and these individuals need time to in the Elderly
adjust to their situations. Listen to them as they
express these fears and be patient and under- Although most elderly individuals remain men-
standing. If they cannot discuss their feelings, tally alert until death, some experience periods of
accept this and provide supportive care (figure confusion and disorientation. Signs of confusion
10-16). or disorientation include talking incoherently,
not knowing their own names, not recognizing
others, wandering aimlessly, lacking awareness
of time or place, displaying hostile and combat-
ive behavior (figure 10-17), hallucinating, regress-
FIGURE 10-16 Provide supportive care and listen FIGURE 10-17 Hostile or combative behavior
to sick individuals as they express their fears. often signals feelings of frustration or confusion.
288 CHAPTER 10
ing in behavior, paying less attention to personal some cases, acute dementia. When the symptoms
hygiene, and being unable to respond to simple are caused by permanent, irreversible damage to
commands or follow instructions. brain cells, the condition is called chronic demen-
tia. Cerebrovascular accidents, arteriosclerosis,
and TIAs can be contributing causes to chronic
CAUSES OF CONFUSION dementia. One modern theory suggests that
chronic dementia is caused by either a complete
AND DISORIENTATION lack or an inadequate amount of an enzyme.
Whatever the cause, chronic dementia is usually
Delirium is the term used when confusion or regarded as a progressive, irreversible disease.
disorientation is a temporary condition caused Alzheimer’s disease (AD) is a form of
by a treatable condition. Stress and/or depres- dementia that causes progressive changes in
sion caused by physical or psychosocial changes brain cells. Individuals with AD lack a neurotrans-
is one possible cause. Use of alcohol or chemicals mitter, or chemical, that allows messages to pass
is another. Kidney disease, which interferes with between nerve cells in the brain. This results in
electrolyte balance; respiratory disease, which the death of neurons and the development of
decreases oxygen; or liver disease, which inter- neuritic plaques (deposits of protein) and neuro-
feres with metabolism, are other causes. Elderly fibrillary tangles. Alzheimer’s disease can occur
individuals are also more sensitive to medica- in individuals as young as 40 years of age, but fre-
tions, and drugs can sometimes accumulate in quently occurs in those in their 60s and 70s. The
the body and cause confusion and disorienta- cause is unknown, but there are many theories
tion. Even poor nutrition or lack of fluid intake currently being researched. A genetic defect, a
can interfere with mental ability. Frequently, missing enzyme, toxic effects of aluminum, a
identification and treatment of any of these con- virus, and the faulty metabolism of glucose have
ditions decreases and even eliminates the confu- all been implicated as possible causes. Whatever
sion and disorientation. For example, changing a the cause, AD is viewed as a terminal, incurable
medication or giving it in smaller doses may brain disease usually lasting from 3 to 10 years.
restore normal function. In the early stages, the individual exhibits
Disease and/or damage to the brain can self-centeredness, a decreased interest in social
sometimes result in chronic confusion or disori- activities, memory loss, mood and personality
entation. A cerebrovascular accident, or changes, anxiety, agitation, depression, poor
stroke, which damages brain cells, is one possible judgment, confusion regarding time and place,
cause. A blood clot can obstruct blood flow to the and an inability to plan and follow through with
brain, or a vessel can rupture and cause hemor- many activities of daily living (figure 10-18). As
rhaging in the brain. Arteriosclerosis, a condi- the disease progresses, nighttime restlessness
tion in which the walls of blood vessels become and wandering occur, mood swings become fre-
thick and lose their elasticity, is common in quent, personal hygiene is ignored, confusion
elderly individuals. If the vessels become narrow and forgetfulness become severe, perseveration
because of deposits of fat and minerals, such as or repetitious behavior occurs, the ability to
calcium, the condition is called atherosclero- understand others and/or speak coherently
sis. These conditions can cause transient decreases, weight fluctuates, paranoia and hallu-
ischemic attacks (TIAs), or ministrokes, which cinations increase, and full-time supervision
result in temporary periods of diminished blood becomes necessary. In the terminal stages, the
flow to the brain. Each time an attack occurs, individual experiences total disorientation re-
more damage to brain cells results. garding person, time, and place; becomes inco-
Dementia, also called brain syndrome, is a herent and is unable to communicate with words;
loss of mental ability characterized by a decrease loses control of bladder and bowel functions;
in intellectual ability, loss of memory, impaired develops seizures; loses weight despite eating a
judgment, personality change, and disorienta- balanced diet; becomes totally dependent; and
tion. When the symptoms are caused by high finally, lapses into a coma and dies. Death is fre-
fever, kidney infection, dehydration, hypoxia quently caused by pneumonia, infections, and
(lack of oxygen), drug toxicity, or other treatable kidney failure. Progress through the various
conditions, the condition is called delirium or, in stages of this disease varies among individuals.
Geriatric Care 289
CARING FOR
CONFUSED OR
DISORIENTED
INDIVIDUALS
Whatever the cause of confusion or disori-
entation, certain courses of care should be
followed. A primary concern is to provide a safe
and secure environment. Dangerous objects such
as drugs, poisons, scissors, knives, razors, guns,
power tools, cleaning solutions, and matches and
lighters should be kept out of reach and in a
locked area. If the individual tends to wander,
doors and windows should be secure. In severe
cases, special sensors may be attached to the
leg or wrist of the disoriented individual (figure
10-19). The sensors alert others if the individual
starts to leave a specific area.
Following the same routine is also important.
Meals, baths, dressing, walks, and bedtime should
each occur at approximately the same time each
day. Any change in routine can cause stress and
confusion. Even though the individual should be
FIGURE 10-18 A patient with Alzheimer’s dis- encouraged to be as active as possible, activities
ease may forget how common objects are used and
should be kept simple and last for short periods
have problems with normal activities of daily living.
of time (figure 10-20). A calm, quiet environment
is also important. Loud noises, crowded rooms,
Diagnosing AD is difficult because there is

no specific test that can be used. Currently, diag-
nosis is confirmed when neuritic plaques are
found during an autopsy after death. However,
researchers are currently evaluating two new
high-technology brain scans that may assist in
identifying AD in early stages. One scan checks
for low levels of glucose metabolism in the hip-
pocampus, a key memory center in the brain,
because hippocampus shrinking is an indication
of AD. A second scan uses magnetic resonance
spectroscopy (MRS) to examine the biochemical
activity in the brain of two neurochemicals typi-
cally altered in AD. Research is also being con-
ducted to develop a blood test that checks for low
levels of a protein called beta-amyloid 40 because
low levels of this protein appear to indicate a high
risk for developing AD. Although there is no cure
for AD, several different medications have shown
promise in improving memory and thinking skills FIGURE 10-19 Special sensors may be attached
in the earlier stages of the disease. For this reason, to the leg or wrist of a wandering or disoriented
early diagnosis and intervention is essential. individual.
290 CHAPTER 10
FIGURE 10-20 Activities for an individual who is

confused or disoriented should be kept simple and
last for short periods of time.
and excessive commotion can cause the individ-

ual to become agitated and even more disori-
ented. FIGURE 10-21 A large calendar may help orient
a person to days and special events.
Reality orientation (RO) consists of activi-
ties that help promote awareness of person, time,
and place. The activities can be followed by any-
one caring for the confused individual, whether close the curtains, use night lights if neces-
the care is in the home or in a long-term care sary, and promote quiet and rest.
facility. Some aspects of reality orientation are ♦ Speak slowly and clearly and ask clear and
the following: simple questions.
♦ Be calm and gentle when approaching the ♦ Never rush or hurry the individual.
individual. ♦ Repeat instructions patiently. Allow time for
♦ Address the person by the name they prefer, the individual to respond.
for example, “Mr. Smith” or “Mike.” ♦ Encourage conversations about familiar things
♦ Avoid terms such as “sweetie,” “baby,” and or current events.
“honey.” ♦ Allow the person to reminisce or remember
♦ State your name and correct the person if he past experiences.
or she calls you a wrong name. For example, if ♦ Encourage the use of a television or radio, but
a patient thinks you are his or her daughter, avoid overstimulating the individual.
say, “I am not your daughter Lisa. I am Mrs.
Simmers, your nurse for today.” ♦ Make sure the individual uses sensory aids
such as glasses and hearing aids (if needed),
♦ Make constant references to day, time, and and that the devices are in good working
place. “It is 8:00 Tuesday morning and time for order.
breakfast.”
♦ Keep familiar objects and pictures within view.
♦ Use clocks, calendars, and information boards Avoid moving the person’s furniture or belong-
to point out time, day, and activities (figure ings.
10-21).
♦ Do not argue with incorrect statements.
♦ Maintain a constant, limited routine. Gently provide correct information if the per-
♦ Keep the individual oriented to day night son is able to accept the information without
cycles. During the day, encourage the person agitation. For example, when a person states it
to wear regular clothes. Also, open the cur- is time to dress for work, say, “You don’t have to
tains and point out the sunshine. At night, go to work today. You retired seven years ago.”
Geriatric Care 291
♦ Do not hesitate to use touch, if culturally times. Continual assessment of the individual’s
appropriate, to communicate with the person, abilities and problems is needed to design a
unless this causes agitation (figure 10-22). health care program that will allow the individual
to function within the level of his or her ability.
♦ Avoid arguments or recriminations. When you Patience, consistency, and sincere caring are
find an elderly resident in the wrong area, do
essential on the part of the health care provider.
not say, “You know you are not supposed to be
here.” Instead, say, “Let me show you how to
get to your room.”
the assignment sheet for 10:4, Confusion and Dis-
♦ Encourage independence and self-help when- orientation in the Elderly.
ever possible.
♦ Always treat the person with respect and dig-
nity. 10:5 INFORMATION
Reality orientation is usually effective during Meeting the Needs of the Elderly
the early stages of confusion or disorientation. In Providing care to the elderly can be a challenging
later stages, when the individual is not able to but rewarding experience. It is important to
respond, it can cause increased anxiety and agi- remember that the needs of the elderly do not
tation. When patient assessment shows that this differ greatly from the needs of any other indi-
is occurring, avoid confronting the patient with vidual. They have the same physical and psycho-
reality. For example, do not tell a patient who logical needs as any person at any age. However,
wants to see her husband that her husband died these needs are sometimes intensified by physi-
10 years ago. Instead, ask her to tell you about her cal or psychosocial changes that disrupt the nor-
husband and allow her to reminisce. Provide sup- mal life pattern. When this occurs, the elderly
portive care to allow the patient to maintain dig- individual needs understanding, acceptance, and
nity and express feelings. the knowledge that someone cares.
Caring for a confused or disoriented individ- A few other factors must be considered when
ual can be frustrating and even frightening at caring for elderly individuals. One is the impor-
tance of meeting cultural needs. Culture can be
defined as the values, beliefs, ideas, customs, and
characteristics that are passed from one genera-
tion to the next. An individual’s culture can affect
language, food habits, dress, work, leisure activi-
ties, and health care. Culture creates differences
in individuals. For example, a person may speak a
different language or have specific likes or dis-
likes about food or dress. It is important for the
health care worker to learn about a person’s cul-
ture, and about the person’s likes, dislikes, and
beliefs. This allows the health care worker to pro-
vide care that shows a respect and acceptance of
the cultural differences. (Cultural diversity is dis-
cussed in greater detail in Chapter 9 of this text.)
Religious needs are another important aspect
of care. Religion can be defined as the spiritual
beliefs and practices of an individual. Like cul-
ture, religious or spiritual beliefs can affect the
lifestyle of an individual. Diet, days of worship,
practices relating to birth and death, and even
acceptance of medical care can be affected. The
FIGURE 10-22 Do not hesitate to use touch, if beliefs of specific religions are discussed in table
culturally appropriate, to communicate with an 9-2 in Chapter 9:3 of this text. It is important to
individual who is disoriented. accept an individual’s beliefs without bias. It is
292 CHAPTER 10
equally important that health care workers do A final aspect of meeting the needs of the
not force their own religious beliefs on the indi- elderly is to respect and follow the patient’s
viduals for whom they provide care. For example, rights. Patients’ rights are discussed in Chapter
if a patient asks, “Do you believe in life after 5:3 of this textbook. These rights assure the elderly
death?” a health care worker may respond by individual of “kind and considerate care,” and
saying, “How do you feel?” or “You have been provide for meeting individual needs. One pro-
thinking about the meaning of life.” This allows gram that exists to ensure the rights of the elderly
patients to express their own feelings and is the Ombudsman Program. It was developed by
thoughts. Other ways the health care worker can the federal government in its Older Americans
show respect and consideration for a person’s Act. Each state has its own program designed to
religious beliefs include proper treatment of reli- meet federal standards. Basically, an ombuds-
gious articles, such as a Bible or Koran; allowing a man is a specially trained individual who works
person to practice religion with prayer, obser- with the elderly and their families, health care
vance of religious holidays, or participation in providers, and other concerned individuals to
religious services; honoring a patient’s requests improve quality of care and quality of life. The
for special foods; and providing privacy during ombudsman may investigate and try to resolve
clergy visits (figure 10-23). complaints, suggest improvements for health
Freedom from abuse is another important care, monitor and enforce state and/or federal
aspect of care. Abuse of the elderly can be regulations, report problems to the correct agency,
physical, verbal, psychological, or sexual. Han- and provide education for individuals involved in
dling the individual roughly; denying food, water, the care of the elderly. Although the role of the
or medication; yelling or screaming at the per- ombudsman may vary from state to state, it is
son; or causing fear are all forms of abuse. Abuse important for the health care worker to cooperate
is sometimes difficult to prove. Frequently, the and work effectively with the ombudsman to
abuser is a family member or caretaker. Elderly ensure that the needs of the elderly are met.
individuals may want to protect the abuser or
may even feel that they deserve the abuse. All STUDENT: Go to the workbook and complete
states have laws requiring the reporting of any the assignment sheet for 10:5, Meeting the Needs of
suspected abuse. It is important for any health the Elderly.
care worker who sees or suspects abuse of the
elderly to report it to the proper agency.
CHAPTER 10 SUMMARY
Geriatric care is care provided to elderly indi-
viduals. Because this age group uses health care
services frequently, and many individuals are
now living longer, it is important for the health
care worker to understand the special needs of
the elderly population.
Many myths, or false beliefs, exist regarding
elderly individuals. Examples include the belief
that most elderly individuals are cared for in
long-term care facilities, are incompetent and
incapable of making decisions, live in poverty,
do not want to work, and are unhappy and lone-
ly. Although these beliefs may be true for some
elderly individuals, they are not true for the ma-
jority.
FIGURE 10-23 Respect religious needs and Physical changes occur in all individuals as a
provide privacy while a resident is visiting with a normal part of the aging process. It is important
member of the clergy. to remember that most of the changes are grad-
Geriatric Care 293

People living to 200 years of age?
Aging has always been considered a normal deterioration of the human body. This con-
cept changed when Cynthia Kenyon, a geneticist at the University of California, discovered
a set of genes in worms that seemed to regulate aging. By suppressing the action of one of
the genes, Kenyon was able to increase a worm’s life span by six times and keep it young.
Research started with a mutant tiny nematode worm, about 1 millimeter long, that
appeared to live about 50 percent longer than other nematode worms. By looking for mutant
genes, Kenyon discovered the daf-2 gene, a gene that controls the aging process. Further
research showed that the daf-2 gene is a protein that allows body tissues to respond to hor-
mones. The mutant daf-2 gene reduced this activity, making the tissue less responsive to
hormones and allowing it to delay the aging process. A second gene, the daf-16 gene, was
identified as the fountain of youth gene because it promotes youthfulness. These genes
allowed the mutant worms not only to delay the aging process, but also to remain youthful,
similar to a 95-year-old functioning like a 45-year-old. The research showed that aging is
regulated by hormones and the endocrine system. By slowing the action of the hormones,
aging can be postponed and age-related diseases can be prevented. This is because age is
the largest risk factor for many diseases. An individual is much more likely to experience
development of a cancerous tumor at age 70 than at age 30.
Other researchers using this information are extending the life span of mice by more
than 30 percent and are continuing to experiment with other mammals that have genes
similar to those of humans. Their goal is to develop drugs that mimic the effects of the genes
in the long-lived animals. If they succeed, many of the age-related diseases may be prevent-
able, and individuals may remain youthful and productive throughout their life spans.
ual and occur over a long period of time. The with these individuals. Providing a safe and se-
physical changes may impose some limitations cure environment, following a set routine, pro-
on the activities of the individual. If the health moting reality orientation, and giving support-
care worker is aware of these changes and is able ive care can allow individuals to function to the
to provide individuals with ways to adapt to and best of their abilities.
cope with the changes, many elderly individuals Meeting the cultural and religious needs of
can enjoy life even with physical limitations. the elderly is also essential. In addition, it is im-
Psychosocial changes also create special portant for health care workers to respect and
needs in the elderly. Retirement, death of a follow the “rights” of elderly individuals and to
spouse and of friends, changes in social relation- protect the elderly from abuse.
ships, new living environments, loss of indepen-
dence, and disease and disability can all cause
stress and crisis for an individual. With support, INTERNET SEARCHES
understanding, and patience, health care work-
ers can assist elderly individuals as they learn to Use the suggested search engines in Chapter 12:4
accommodate the changes and to function in of this textbook to search the Internet for addi-
new situations. tional information on the following topics:
Although most elderly individuals remain
1. Gerontology: search words such as gerontology,
mentally alert until death, some have periods of
geriatrics, and geriatric assistant for additional
confusion and disorientation. This is sometimes
information on aging
a temporary condition that can be corrected.
Other times, disease and/or damage to the brain 2. Long-term care facilities: search for informa-
results in chronic confusion or disorientation. tion on assisted-living, independent living,
Special techniques should be used in dealing extended-care, and adult daycare facilities;
294 CHAPTER 10
meals on wheels; and other resources for the 4. What measures can be taken to help an indi-
elderly vidual adapt or cope with the following physi-
cal changes of aging?
3. Diseases: search for additional information on
senile lentigines, osteoporosis, arthritis, a. dry, itching skin
emphysema, bronchitis, cerebrovascular
b. increased sensitivity to cold
accident, arteriosclerosis, atherosclerosis,
transient ischemic attack, dementia, and c. hearing loss and the inability to hear high-
Alzheimer’s disease frequency sounds
4. Disabilities: search for information on different d. difficulty in chewing and a decreased sense
types of assistive devices for individuals with of taste
disabilities e. indigestion, flatulence, and constipation
5. Federal government programs: search for f. weakness, dizziness, and dyspnea while
information on the Older American Act, exercising
Omnibus Budget Reconciliation Act of 1987,
and an ombudsman 5. Differentiate between disease and disability.
6. List four (4) factors that cause psychosocial
changes in aging. For each factor, provide at
REVIEW QUESTIONS least two (2) examples of ways an individual
can be helped to adapt or cope with the
1. Define gerontology. change.
2. Why is it important for a health care worker to 7. Differentiate between acute dementia
differentiate between myths and facts of aging? (delirium) and chronic dementia. Identify
four (4) causes for each type of dementia.
3. Identify factors that can decrease the speed
and degree of physical changes of aging. 8. Why is it important to respect an individual’s
Identify factors that can cause an increase. cultural and religious beliefs?
CHAPTER 11 Nutrition
and Diets
Chapter Objectives
Observe Standard
Precautions
◆ Define the term nutrition and list the effects of
good and bad nutrition
◆ Name the six groups of essential nutrients and
their functions and sources
◆ Differentiate between the processes of
digestion, absorption, and metabolism
Caution ◆ Create a sample daily menu using the five
major food groups and recommendations on
My Pyramid
on Federal Law ◆ Use the body mass index (BMI) graph to
determine an individual’s BMI
Math Skill ◆ Calculate an individual’s daily required caloric
intake to maintain current weight
Legal Responsibility ◆ Name, describe, and explain the purposes of at

least eight therapeutic diets
Science Skill
Career Information
Technology
296 CHAPTER 11
KEY TERMS
absorption essential nutrients nutritional status
anorexia (an-oh-rex-ee-ah) fat-restricted diets obesity
antioxidants fats osteoporosis (os-tee-oh-
atherosclerosis (ath-eh-row- hypertension (high-purr- pour-oh-sis)
skleh-row-sis) ten-shun) overweight
basal metabolic rate (BMR) kilocalorie (kcal) (kill-oh- peristalsis (per-eh-stall-sis)
(base-al met-ah-ball-ik) kall-oh-ree) protein diets
bland diet lipids proteins
body mass index (BMI) liquid diets regular diet
calorie low-cholesterol diet sodium-restricted diets
calorie-controlled diets low-residue diet soft diet
carbohydrates malnutrition therapeutic diets (ther-ah-
cellulose metabolism (meh-tab-oh- pew-tick)
cholesterol (co-less-ter-all) liz-em) underweight
diabetic diet minerals vitamins
digestion nutrition wellness
11:1 Information ease, appetite, posture, complexion, mental abil-

ity, and emotional and psychological health. The
Fundamentals of Nutrition immediate effects of good nutrition include a
healthy appearance, a well-developed body, a
People enjoy food and like to discuss it. Most good attitude, proper sleep and bowel habits,
people know that there is an important relation- a high energy level, enthusiasm, and freedom
ship between food and good health. However, from anxiety. In addition, the effects of good
many people do not know which nutrients are nutrition accumulate throughout life and may
needed or why they are necessary. They are not prevent or delay diseases or conditions such as
able to select proper foods in their daily diets in the following:
order to promote optimum health. Therefore, it is
important for every health care worker to have a ♦ Hypertension: high blood pressure; may be
solid understanding of basic nutrition. With this caused by an excess amount of fat or salt in
understanding, the health care worker can both the diet; can lead to diseases of the heart,
practice and promote good nutrition. blood vessels, and kidneys
Nutrition includes all body processes relat- ♦ Atherosclerosis: condition in which arteries
ing to food. These include digestion, absorption, are narrowed by the accumulation of fatty
metabolism, circulation, and elimination. These substances on their inner surfaces; thought to
processes allow the body to use food for energy, be caused by a diet high in saturated fats and
maintenance of health, and growth. Nutritional cholesterol; can lead to heart attack or stroke
status refers to the state or condition of one’s
nutrition. The goal is, of course, to be in a state of ♦ Osteoporosis: condition in which bones
good nutrition and to maintain wellness, a state become porous (full of tiny openings) and
of good health with optimal body function. To do break easily; one cause is long-term deficien-
this, one must choose foods that are needed by cies of calcium, magnesium, and vitamin D
the body, and not just foods that taste good. ♦ Malnutrition: the state of poor nutrition;
Nutrition plays a large role in determining may be caused by poor diet or illness. Symp-
height, weight, strength, skeletal and muscular toms include fatigue, depression, poor pos-
development, physical agility, resistance to dis- ture, being overweight or underweight, poor
Nutrition and Diets 297
TABLE 11-1 The Six Essential Nutrient Groups

NUTRIENT
GROUPS FUNCTIONS
Carbohydrates Provide heat and energy

Supply fiber for good digestion and
elimination
Lipids (Fats) Provide fatty acids needed for
growth and development
Provide heat and energy
Carry fat-soluble vitamins (A, D, E,
and K) to body cells
FIGURE 11-1 This child shows many of the signs Proteins Build and repair body tissue
of severe malnutrition. (Courtesy of the Centers for Provide heat and energy
Disease Control and Prevention, Public Health Help produce antibodies
Image Library)
Vitamins Regulate body functions
Build and repair body tissue
complexion, lifeless hair, and irritability (fig-
ure 11-1). It can cause deficiency diseases, Minerals Regulate body functions
poor muscular and skeletal development, Build and repair body tissue
reduced mental abilities, and even death. Mal-
Water Carries nutrients and wastes to and
nutrition is most likely to affect individuals
from body cells
living in extreme poverty, patients undergoing
Regulates body functions
drug therapy such as treatment for cancer,
infants, young children, adolescents, and the
elderly. Obesity is also a form of malnutrition,
caused by excess food consumption. The main sources of carbohydrates are
breads, cereals, noodles or pastas, crackers, pota-
toes, corn, peas, beans, grains, fruits, sugar, and
11:2 INFORMATION syrups.
Cellulose is the fibrous, indigestible form of
Essential Nutrients plant carbohydrate. It is important because it
Essential nutrients are composed of chemical provides bulk in the digestive tract and causes
elements found in food. They are used by the regular bowel movements. The best sources of
body to perform many different body functions. cellulose are bran, whole-grain cereals, and
As the body uses the elements, they are replaced fibrous fruits and vegetables.
by elements in the food one eats. The essential
nutrients are divided into six groups. The six
groups and the specific functions of each group LIPIDS (FATS)
are shown in table 11-1.
Lipids, commonly called fats and oils, are
organic compounds. Three of the most common
CARBOHYDRATES lipids found in both food and the human body
are triglycerides (fats and fatty acids), phospho-
Carbohydrates are the major source of readily lipids (lecithin), and sterols (cholesterol). Lipids
usable human energy. They are commonly called are also made of carbon, hydrogen, and oxygen,
starches or sugars. Carbohydrates are a cheaper but they contain more oxygen than carbohy-
source of energy than are proteins and fats drates. Fats provide the most concentrated form
because they are mainly produced by plants. of energy but are a more expensive source of
They are easily digested, grow well in most cli- energy than carbohydrates. Fats also maintain
mates, and keep well without refrigeration. They body temperature by providing insulation, cush-
are made of carbon, hydrogen, and oxygen. ion organs and bones, aid in the absorption of
298 CHAPTER 11
fat-soluble vitamins, and provide flavor to meals. ing plant foods carefully can provide a mixture of
The main sources of fats include butter, marga- amino acids from incomplete proteins that con-
rine, oils, cream, fatty meats, cheeses, and egg tain all the essential amino acids. It is important
yolk. for a vegetarian to select foods that meet these
Fats are also classified as saturated or polyun- dietary needs.
saturated. Saturated fats are usually solid at room
temperature. Examples include the fats in meats,
eggs, whole milk, cream, butter, and cheeses.
Polyunsaturated fats are usually soft or oily at
VITAMINS
room temperature. Examples include vegetable Vitamins are organic compounds that are essen-
oils, margarines and other products made from tial to life. They are important for metabolism,
vegetable oils, fish, and peanuts. tissue building, and regulation of body processes.
Cholesterol is a sterol lipid found in body They allow the body to use the energy provided
cells and animal products. It is used in the pro- by carbohydrates, fats, and proteins. Only small
duction of steroid hormones, vitamin D, and bile amounts of vitamins are required, and a well-bal-
acids. Cholesterol is also a component of cell anced diet usually provides the required vitamins.
membranes. Common sources are egg yolk, fatty An excess amount of vitamins or a deficiency of
meats, shellfish, butter, cream, cheeses, whole vitamins can cause poor health.
milk, and organ meats (liver, kidney, and brains). Some vitamins are antioxidants, organic
In addition, cholesterol is synthesized (manufac- molecules that help protect the body from harm-
tured) by the liver. Cholesterol is transported in ful chemicals called free radicals. In the body,
the bloodstream mainly by two carrier molecules oxygen used during metabolism causes free radi-
called lipoproteins. They are known as HDL and cals to form. Free radicals can damage tissues,
LDL, or high-density and low-density lipopro- cells, and even genes in the same way that oxygen
tein. HDL, commonly called “good” cholesterol, causes metals to rust or apples to become brown.
tends to transport cholesterol back to the liver Research is indicating that free radicals can lead
and prevents plaque from accumulating on the to the development of chronic diseases such as
walls of arteries. LDL, commonly called “bad” cancer, heart disease, and arthritis. Antioxidants,
cholesterol, tends to contribute to plaque buildup found mainly in fruits and vegetables, deactivate
and an excess amount leads to atherosclerosis. the free radicals and prevent them from damag-
Consequently, it is advisable to limit the intake of ing body cells. The main antioxidant vitamins are
foods that contain fats from animal sources. vitamins A, C, and E.
Vitamins are usually classified as water solu-
ble or fat soluble. Water-soluble vitamins dissolve
PROTEINS in water, are not normally stored in the body, and
are easily destroyed by cooking, air, and light.
Proteins are the basic components of all body Fat-soluble vitamins dissolve in fat, can be stored
cells. They are essential for building and repair- in the body, and are not easily destroyed by cook-
ing tissue, regulating body functions, and providing, air, and light. Some of the vitamins along
ing energy and heat. They are made of carbon, with their sources and functions are listed in table
hydrogen, oxygen, and nitrogen, and some also 11-2.
contain sulfur, phosphorus, iron, and iodine.
Proteins are made up of 22 “building blocks”
called amino acids. Nine of these amino acids are
essential to life. The proteins that contain these
MINERALS
nine are called complete proteins. The best sources Minerals are inorganic (nonliving) elements
of complete proteins are animal foods such as found in all body tissues. They regulate body flu-
meats, fish, milk, cheeses, and eggs. Proteins that ids, assist in various body functions, contribute
contain any of the remaining 13 amino acids and to growth, and aid in building tissues. Some min-
some of the 9 essential amino acids are called erals, such as selenium, zinc, copper, and manga-
incomplete proteins. Sources of incomplete pro- nese, are antioxidants. Table 11-3 lists some of
teins are usually vegetable foods such as cereals, the minerals essential to life, their sources, and
soybeans, dry beans, peas, corn, and nuts. Choos- their main functions.
TABLE 11-2 Vitamins
Vitamins Best Sources Functions
Fat-Soluble Vitamins
Vitamin A Liver, fatty fish Growth and development
(Retinol) Butter, margarine Health of eyes
Whole milk, cream, cheese Structure and functioning of the cells of the skin and
Egg yolk mucous membranes
Leafy green and yellow vegetables Antioxidant to protect cells from free radicals
Vitamin D Sunshine (stimulates production in skin) Growth
(Calciferol) Fatty fish, liver Regulates calcium and phosphorous absorption and
Egg yolk metabolism
Butter, cream, fortified milk Builds and maintains bones and teeth
Vitamin E Vegetable oils, butter, margarine Necessary for protection of cell structure, especially
(Tocopherol) Peanuts red blood cells and epithelial cells
Egg yolk Antioxidant to inhibit breakdown of vitamin A and
Dark green leafy vegetables some unsaturated fatty acids
Soybeans and wheat germ
Vitamin K Spinach, kale, cabbage, broccoli Normal clotting of blood
Liver Formation of prothrombin
Soybean oil
Cereals
Water-Soluble Vitamins
Thiamine (B1) Enriched bread and cereals Carbohydrate metabolism
Liver, heart, kidney, lean pork Promotes normal appetite and digestion
Potatoes, legumes Normal function of nervous system
Riboflavin (B2) Milk, cheese, yogurt, eggs Carbohydrate, fat, and protein metabolism
Enriched breads and cereals Health of mouth tissue
Dark green leafy vegetables Healthy eyes
Liver, kidney, heart, fish
Niacin Meats (especially organ meats) Carbohydrate, fat, and protein metabolism
(Nicotinic Acid) Poultry and fish Healthy skin, nerves, and digestive tract
Enriched breads and cereals
Peanuts and legumes
Pyridoxine (B6) Liver, kidney, pork Protein synthesis and metabolism
Poultry and fish Production of antibodies
Vitamin B12 Liver, kidney, muscle meats, seafood Metabolism of proteins
(Cobalamin) Milk, cheese Production of healthy red blood cells
Eggs Maintains nerve tissue
Vitamin C Citrus fruits, pineapple Healthy gums
(Ascorbic Acid) Melons, berries, tomatoes Aids in wound healing
Cabbage, broccoli, green peppers Aids in absorption of iron
Formation of collagen
Folic Acid Green leafy vegetables Protein metabolism
(Folacin) Citrus fruits Maturation of red blood cells
Organ meats, liver Formation of hemoglobin
Whole-grain cereals, yeast Synthesis of DNA
Reduces risk for neural tube defect (spina bifida) in
fetus—important for pregnant women to consume
recommended daily amount
300 CHAPTER 11
TABLE 11-3 Minerals

Minerals Best Sources Functions
Calcium (Ca) Milk and milk products Develops/maintains bones and teeth
Cheese Clotting of the blood
Salmon and sardines Normal heart and muscle action
Some dark green leafy vegetables Nerve function
Phosphorus (P) Milk and cheese Develops/maintains bones and teeth
Meat, poultry, fish Maintains blood acid–base balance
Nuts, legumes Metabolism of carbohydrates, fats, and
Whole-grain cereals proteins
Constituent of body cells
Magnesium (Mg) Meat, seafood Constituent of bones, muscles, and red blood
Nuts and legumes cells
Milk and milk products Healthy muscles and nerves
Cereal grains Metabolism of carbohydrates and fats
Fresh green vegetables
Sodium (Na) Salt Fluid balance, acid–base balance
Meat and fish Regulates muscles and nerves
Poultry and eggs Glucose (sugar) absorption
Milk, cheese
Potassium (K) Meat Fluid balance
Milk and milk products Regular heart rhythm
Vegetables Cell metabolism
Oranges, bananas, prunes, raisins Proper nerve function
Cereals Regulates contraction of muscles
Chlorine (Cl) Salt Fluid balance
(Chloride) Meat, fish, poultry Acid–base balance
Milk, eggs Formation of hydrochloric acid
Sulfur (S) Meat, poultry, fish Healthy skin, hair, and nails
Eggs Activates energy-producing enzymes
Iron (Fe) Liver, muscle meats Formation of hemoglobin in red blood cells
Dried fruits Part of cell enzymes
Egg yolk Aids in production of energy
Dark green leafy vegetables
Iodine (I) Saltwater fish Formation of hormones in thyroid gland
Iodized salt Regulates basal metabolic rate
Copper (Cu) Liver, organ meats, seafood Utilization of iron
Nuts, legumes Component of enzymes
Whole-grain cereals Formation of hemoglobin in red blood cells
Fluorine (Fl) (Fluoride) Fluoridated water Healthy teeth and bones
Fish, meat, seafood
Zinc (Zn) Seafood, especially oysters Component of enzymes and insulin
Eggs Essential for growth and wound healing
Milk and milk products
Selenium (Se) Organ meats Metabolism of fat
Seafood Acts as antioxidant
food chemically, and moves the food through the

WATER digestive system. There are two types of digestive
action: mechanical and chemical. During
Water is found in all body tissues. It is essential
mechanical digestion, food is broken down by
for the digestion (breakdown) of food, makes up
the teeth and moved through the digestive tract
most of the blood plasma and cytoplasm of cells,
by a process called peristalsis, a rhythmic,
helps body tissues absorb nutrients, and helps
wavelike motion of the muscles. During chemical
move waste material through the body. Although
digestion, food is mixed with digestive juices
water is found in almost all foods, the average
secreted by the mouth, stomach, small intestine,
person should still drink six to eight glasses of
and pancreas. The digestive juices contain
water each day to provide the body with the water
enzymes, which break down the food chemically
it needs.
so the nutrients can be absorbed into the blood.
11:3 INFORMATION
Utilization of Nutrients
ABSORPTION
Before the body is able to use nutrients, it must After the food is digested, absorption occurs.
break down the foods that are eaten to obtain the Absorption is the process in which blood or
nutrients and then absorb them into the circula- lymph capillaries pick up the digested nutrients.
tory system. These processes are called digestion The nutrients are then carried by the circulatory
and absorption (figure 11-2). The actual use of the system to every cell in the body. Most absorption
nutrients by the body is called metabolism. These occurs in the small intestine, but water, salts, and
processes are discussed in greater detail in Chap- some vitamins are absorbed in the large intestine.
ter 7:11 of this textbook.
METABOLISM
DIGESTION After nutrients have been absorbed and carried
Digestion is the process by which the body to the body cells, metabolism occurs. This is the
breaks down food into smaller parts, changes the process in which nutrients are used by the cells
1. Mouth: Teeth and tongue begin mechanical 2. Salivary Glands: Begin chemical digestion
digestion by breaking apart food. as salivary amylase begins to change
starch to maltose.
3. Esophagus: Peristalsis and gravity move

food along. 4. Stomach: Hydrochloric acid prepares
the gastric area for enzyme action.
Pepsin breaks down proteins. In children,
rennin breaks down milk proteins. Lipase
starts to act on emulsified fats.
5. Liver: Produces bile.
8. Small Intestine: Produces enzymes and

6. Gallbladder: Stores bile and releases it into prepares foods for absorption. Lactase
small intestine to emulsify fats. converts lactose, maltase converts maltose,
and sucrase converts sucrose to simple sugars.
Peptidases reduce peptides to amino acids.
Most absorption occurs here.
7. Pancreas: Enzymes are released into the

small intestine. Pancreatic amylase breaks
down starch. Steapsin (lipase) breaks down 9. Large Intestine: Absorbs water and some
fats. Pancreatic proteases break down other nutrients, and collects food residue
proteins into peptides. for excretion.
FIGURE 11-2 The processes of digestion and absorption.

302 CHAPTER 11
for building tissue, providing energy, and regulat- Although the major food groups are a key to
ing various body functions. During this process, healthy meal plans, variety, taste, color, aroma,
nutrients are combined with oxygen, and energy texture, and general food likes and dislikes must
and heat are released. Energy is required for vol- also be considered. If food is not appealing, peo-
untary work, such as swimming or houseclean- ple will usually not eat it even though it is
ing, and for involuntary work, such as breathing healthy.
and digestion. The rate at which the body uses Sound and sensible nutritional principles can
energy just for maintaining its own tissue, with- be found in the booklet published by the U.S.
out doing any voluntary work, is called the basal Department of Agriculture (USDA) and entitled
metabolic rate, or BMR. The body needs Finding Your Way to a Healthier You: Dietary
energy continuously, so it stores some nutrients Guidelines for Americans. Some guidelines dis-
for future use. These stored nutrients are used to cussed in greater detail in the booklet include:
provide energy when food intake is not adequate
for energy needs. ♦ Make smart choices from every food group. Eat
a variety of foods. Choose different foods from
each of the five major food groups each day.
Adjust the number and size of portions based
11:4 INFORMATION on body weight and nutritional needs. This
helps provide the wide variety of nutrients
Maintenance of Good Nutrition required for good health.
Good health is everyone’s goal, and good nutri-
tion is the best way of achieving and maintaining ♦ Find your balance between food and physical
it. Normally, this is accomplished by eating a bal- activity. Be physically active for at least 30
anced diet in which all of the required nutrients minutes most days of the week. Children,
are included in correct amounts. The simplest teenagers, and adults trying to lose weight
guide for planning healthy meals is the U.S. should be physically active for 60 minutes
Department of Agriculture (USDA) Food Guide, each day. Maintain healthy weight. Determine
which classifies foods into five major food groups. your proper body weight and try to maintain
Foods are arranged in groups containing similar this weight by proper eating habits and exer-
nutrients. This is known as My Pyramid (figure cise.
11-3). The pyramid has rainbow-hued bands run- ♦ Limit fats. Choose a diet low in fat, saturated
ning vertically. Each color represents a different fat, and cholesterol. Eat lean meat, poultry
food group. The width of the bands represents without skin, fish, and low-fat dairy products.
the relative proportionate amount of each group Use fats and oils sparingly and limit fried
that an individual should consume every day. The foods.
importance of exercise is emphasized by the per-
son climbing the side of the pyramid. My Pyra- ♦ Get the most nutrition out of your calories.
mid stresses that one size does not fit everyone. Determine the correct number of calories you
Individuals are encouraged to utilize the My Pyr- should eat daily. Then choose nutritionally
amid Web site (www.mypyramid.gov) to develop rich foods that are high in nutrients but lower
a customized food plan based on age, sex, and in calories. Choose a diet with plenty of vege-
physical activity. This helps an individual to make tables, fruits, and grain products.
smart choices from every food group, determine ♦ Don’t sugarcoat it. Use sugars only in modera-
the required balance between food and physical tion. Limit cookies, candy, cakes, and soft
activity, and gain optimal nutrition from calories drinks. Brush and floss your teeth after eating
consumed. sweet foods.
An example of a food plan for an individual
requiring 2,000 calories per day is shown in table ♦ Reduce sodium (salt) and increase potassium.
11-4. It lists the five major food groups, recom- Use salt and sodium only in moderation. Fla-
mended daily amount, average serving size, and vor foods with herbs and spices. Reduce the
nutrient contents of the foods. A sample menu amount of salty foods. Eat foods high in potas-
using these recommendations is shown in table sium to counteract some of the effect of
11-5. sodium on blood pressure.
FIGURE 11-3 My Pyramid provides the guidelines for a healthier you. (Courtesy of the U.S. Department of
Agriculture, www.mypyramid.gov)
304 CHAPTER 11
TABLE 11-4 My Pyramid for a 2,000 Calorie Diet

RECOMMENDED DAILY AVERAGE RECOMMENDED
FOOD GROUP AMOUNT PORTION SIZE NUTRIENT CONTENT
Grains (Breads, 6 ounces 1 slice bread Carbohydrates; phosphorus;

Cereals, Rice, & 1/2 bagel or English muffin magnesium; potassium; iron;
Pasta) 1/2 cup cooked cereal vitamins B, K, and folic acid
1/2 cup cooked pasta or rice
1 cup dry cereal
Vegetables 2 1/2 cups 1 cup raw leafy vegetables Carbohydrates; iron; calcium;
1/2 cup cooked vegetables potassium; magnesium; vitamins
3/4 cup vegetable juice A, B, C, E, K, and folic acid
Fruits 2 cups 1 medium size fruit Carbohydrates; potassium; vitamin
1/2 cup canned/cooked fruit C and folic acid
1/4 cup dried fruit
1 cup fruit juice
1 cup fresh fruit
Milk, Milk Products, 3 cups 1 cup milk, yogurt, pudding Protein; carbohydrate; fat; calcium;
Yogurt, & Cheese 1 1/2 ounces cheese potassium; sodium; magnesium;
1 cup cottage cheese phosphorus; vitamins A, B12, D,
1 cup ice cream and riboflavin
Meats, Fish, Poultry, 5 1/2 ounces 1 ounce meat, fish, or poultry Proteins; fats; iron; sulfur; copper;
Dry Beans, Eggs, & 1/4 cup dry beans iodine; sodium; magnesium; zinc;
Nuts 1/2 cup cooked beans potassium; phosphorus; chlorine;
1 egg fluorine; vitamins A, B, and D
1 tablespoon peanut butter
1/2 ounce nuts
TABLE 11-5 Sample Menu Using My Pyramid Guidelines

BREAKFAST LUNCH DINNER
1 cup orange juice Tuna fish sandwich: 3 ounces roasted chicken

1 cup dry cereal 2 slices wheat bread 1/2 cup rice
1 slice whole-grain toast 3 ounces tuna 1/2 cup broccoli
1 teaspoon margarine 2 slices tomato 1 cup green salad
1 cup fat-free milk 1 lettuce leaf 1 tablespoon vinegar/oil dressing
1 small banana 8 small raw carrots 1 small dinner roll
1 oatmeal cookie 1/2 teaspoon margarine
1 unsweetened beverage 1 cup fat-free milk
1 cup low-fat fruit yogurt
Suggested snacks: 1/4 cup dried fruit, 1/2 ounce nuts, 2 tablespoons raisins, 1 cup popcorn, 1 medium fruit
♦ Read food labels to know the facts about the fat and try to keep total fat intake between 20
foods you eat. Most foods have a Nutrition Facts and 35 percent of total caloric intake. Look at
label (figure 11-4). Check the label to determine the daily value percentage for each nutrient
the serving size and number of servings in the listed to determine whether the food is nutri-
container. Evaluate the number of calories per tious and worth eating. Avoid empty calories or
serving to determine whether the food is a low- high-caloric foods with no vitamins, minerals,
or high-calorie food. Calculate the amount of carbohydrates, and/or proteins.
Different cultures and races have certain food

Nutrition Facts
Serving Size 1/2 cup (114g)
preferences. Some religions require certain
dietary restrictions that must be observed (see
Servings Per Container 4 table 11-6). Unusual habits are not necessarily
bad. They should be evaluated using the five
Amount Per Serving major food groups as a guide. When habits do
require changing in order to improve nutrition,
Calories 90 Calories from Fat 30
the person making suggestions must use tact,
% Daily Value patience, and imagination. Many food habits are
Total Fat 3g 5% formed during youth, and changing them is a dif-
Saturated Fat 0g 0% ficult and slow process.
Cholesterol 0mg 0%
Sodium 300mg 13%
Total Carbohydrate 13g 4% 11:5 INFORMATION
Dietary Fiber 3g 12%
Sugars 3g Weight Management
Protein 3g Good nutrition and adequate exercise allow
an individual to maintain a normal weight,
Vitamin A 80% • Vitamin C 60% or body weight that is in proportion to body
height. Many charts are available to provide sug-
Calcium 4% • Iron 4%
gested ranges of weight based on an individual’s
• Percent Daily Values are based on a 2,000 calorie diet. Your
daily values may be higher or lower depending on your calorie
height. In addition, a general formula can be used
needs: to calculate an approximate desired weight for
Calories 2,000 2,500 adults. Basic principles include:
Total Fat Less than 65g 80g ♦ Male individuals: For the first 60 inches (5
Sat Fat Less than 20g 25g feet) of height, a male individual should weigh
Cholesterol Less than 300mg 300mg 106 pounds. For each inch over 60 inches, 6
Sodium Less than 2,400mg 2,400mg pounds should be added. For example, a man
Total Carbohydrate 300g 375g measuring 74 inches (6 feet 2 inches) should
Fiber 25g 30g weigh approximately 190 pounds: 106 pounds
plus 84 pounds (6 pounds 14 inches 84)
Calories per gram: equals 190 pounds.
Fat 9 Carbohydrate 4 Protein 4
• •
♦ Female individuals: For the first 60 inches of
FIGURE 11-4 It is important to check food labels height, a female individual should weigh 100
to determine the caloric and nutrient content of pounds. For each inch over 60 inches, 5 pounds
the food. (Courtesy of the Food and Drug should be added. For example, a woman mea-
Administration) suring 68 inches (5 feet 8 inches) should weigh
approximately 140 pounds: 100 pounds plus
40 pounds (5 pounds 8 inches) equals 140
♦ Be aware that alcohol can be harmful to your pounds.
health. If alcohol is consumed, it should be in
moderation. Alcohol should be avoided by ♦ Large-boned individuals: Increase the weight
pregnant women, individuals using medica- by 10 percent for individuals of either sex who
tions, children and adolescents, and individu- have a large bone structure.
als who are driving or engaging in an activity ♦ Small-boned individuals: Decrease the weight
that requires attention or skill. by 10 percent for individuals of either sex who
have a small bone structure.
Following the preceding guidelines will result
in a diet that will maintain and may even improve Even though the above formulas provide a
health. basic desired weight, most research has shown
Food habits also affect nutrition. At times, that a better indication of an individual’s health
habits are based on cultural or religious beliefs. status is body mass index. Body mass index
306 CHAPTER 11
TABLE 11-6 Religious Dietary Restrictions

PORK &
COFFEE & DAIRY PORK
RELIGION TEA ALCOHOL PRODUCTS PRODUCTS MEAT SPECIAL RESTRICTIONS
Baptist Restricted Prohibited Some groups drink coffee

(Strict) and tea
Many are ovolactovegetar-
ians (use eggs and milk,
but no meat)
Buddhist Some Some Some Some sects Many sects are vegetarians
sects sects sects abstain Some sects eat beef and
prohibit prohibit abstain pork
Some may refuse strong
spices
Christian Most Most avoid
Scientist avoid
Greek Wednesdays Wednesdays Avoid food and beverages
Orthodox and Fridays and Fridays before communion
(Eastern during Lent during Lent
Orthodox) and other and other
Holy Days Holy Days
Hindu Most avoid Prohibited Beef prohibited Most are vegetarians
because cow Many do not use eggs as
is sacred they represent life
Islamic, Prohibited Prohibited Do not eat or drink during
Muslim daylight hours in month of
Ramadan
Shellfish forbidden
Meat must be slaughtered
according to specific rules
Jewish Must not be Prohibited Must not be Forbids cooking on Sabbath
(Orthodox) prepared or prepared or Shellfish forbidden
eaten with eaten with Food must be prepared
meat dairy according to Kosher rules
products May fast on certain holy
days
Mormon Prohibited Prohibited Encouraged to Cola and other caffeine
(Latter Day eat sparingly drinks prohibited
Saints) Some fast on the first
Sunday of each month
Roman Refrain from Many avoid food and
Catholic meat on Ash beverages 1 hour prior to
Wednesday communion
and Fridays
during Lent
Seventh Prohibited Prohibited Prohibited Vegetarian diet is encour-
Day aged
Adventist Avoid shellfish
Prohibit foods containing
caffeine
(BMI) is a calculation that measures weight in controlled, an individual is at high risk for devel-
relation to height and correlates this with body fat. opment of hypertension, diabetes mellitus,
It is determined by dividing a person’s weight in coronary heart disease, high cholesterol, cere-
kilograms by height in meters squared. A graphic brovascular accident (stroke), osteoarthritis, gall-
chart showing BMI ranges is the easiest way to bladder disease, breathing problems such as
determine BMI (figure 11-5). The ideal range is sleep apnea, and many other similar conditions.
18.5–24.9. A BMI less than 18.5 indicates the indi- Research has also shown that obesity decreases
vidual is underweight. A BMI greater than 25 is life span and causes many early deaths.
indicative of excess weight and more health risks. Following the principles shown on My Pyra-
mid and in the USDA dietary guidelines is the
easiest way to manage weight. Every person
UNDERWEIGHT AND should become familiar with these principles and
make every attempt to follow them on a daily
OVERWEIGHT basis. Even though poor food habits are hard to
break, it can be done if an individual is motivated
Weight management is used to achieve and main- to change his or her behavior.
tain the desired body weight. The major condi-
tions that occur due to poor nutrition and
improper exercise are underweight, overweight, MEASURING FOOD
and obesity.
Underweight is a body weight that is 10 to ENERGY
15 percent less than the desired weight. Under- Foods vary in the amount of energy they contain.
weight individuals are much more likely to have For example, a candy bar provides more energy
nutritional deficiencies. Causes can include inad- than does an apple. When the body metabolizes
equate intake of food, excessive exercise, severe nutrients to produce energy, heat is also released.
infections, eating disorders, diseases that cause The amount of heat produced during metabo-
anorexia (lack of appetite), and/or starvation. lism is the way the energy content of food is mea-
Treatment involves gradually increasing the sured. This heat is measured by a unit called a
amount of food consumed, eating higher calorie kilocalorie (kcal), or just calorie. The number
foods, counseling and medical treatment for eat- of kilocalories, or calories, in a certain food is
ing disorders or diseases, and decreasing exercise known as that food’s caloric value. Carbohydrates
if excessive exercise is a cause. and proteins provide four calories per gram. Fat
Overweight is a body weight that is 10–20 provides nine calories per gram. Vitamins, min-
percent greater than the average recommended erals, and water do not provide any calories.
weight for a person’s height. Obesity is excessive An individual’s caloric requirement is the
body weight 20 percent or more above the aver- number of kilocalories, or calories, needed by the
age recommended weight. Obesity has become a body during a 24-hour period. Caloric require-
major health concern in the United States. ments vary from person to person, depending on
Research by the National Center for Health Sta- activity, age, size, sex, physical condition, and cli-
tistics shows that more than 30 percent of adults mate. The amount of physical activity or exercise
are obese. This means that more than 60 million is usually the main factor determining caloric
adults in the United States are obese. Statistics requirement, because energy used must be
also show that more than 15 percent of young replaced. An individual who wants to gain weight
people aged 6 to 17 are overweight. The main can decrease activity and increase caloric intake.
causes of obesity are excessive calorie consump- An individual who wants to lose weight can
tion and inadequate physical activity. Genetic, increase activity and decrease caloric intake.
psychological, biochemical (metabolic), socio-
economic, cultural, and environmental factors
can contribute to these conditions. Treatment
involves modifying eating habits and increasing
MANAGING WEIGHT
physical activity. In more severe cases, medical Most people know that maintaining desired body
intervention with medications, counseling, and weight can lead to a longer and healthier life. For
even surgery may be necessary. If obesity is not this reason, many individuals try many different
308 CHAPTER 11
ARE YOU A HEALTHY WEIGHT?

BMI (Body Mass Index)
5
18.
Height*
25
30
6'6"
6'5"
6'4"
6'3"
6'2"
6'1"
6'0"
5'11"
5'10"
5'9"
5'8"
5'7"
5'6"
5'5"
5'4"
5'3"
5'2"
5'1"
5'0"
4'11"
4'10"
50 75 100 125 150 175 200 225 250 275
Pounds† *Without shoes. †Without clothes.
BMI measures weight in relation to height. The BMI ranges shown above are for adults. They are not exact ranges of healthy and
unhealthy weights. However, they show that health risk increases at higher levels of overweight and obesity. Even within the healthy
BMI range, weight gains can carry health risks for adults.
Directions: Find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your
height. Then look to find your weight group.
Healthy Weight BMI from 18.5 up to 25 refers to healthy weight.
Overweight BMI from 25 up to 30 refers to overweight.
Obese BMI 30 or higher refers to obesity. Obese persons are also overweight.
Source: Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2000.
FIGURE 11-5 Body mass index (BMI) helps individuals determine healthy weight ranges. (From Report of
the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2000)
types of diets to lose weight. Research has shown The USDA Dietary Guidelines recommenda-
that even though these diets might lead to weight tions for managing weight include:
loss, they usually do not allow an individual to
♦ Balance calories from foods and beverages
maintain weight when the diet is no longer used.
with calories expended
Most fad diets require eating specific foods, limit-
ing certain food groups, eating large amounts of ♦ Prevent gradual weight gain by making small
one type of food, or using liquid supplements in decreases in daily calories and small increases
place of food. When individuals resume their in physical activity
normal eating habits, the weight that was lost is ♦ Engage in at least 30 minutes or more of
quickly regained. moderate-intensity physical activity most
The best method for weight control is to make days of the week
desired changes slowly. Research has shown that ♦ Consume less than 10 percent of calories from
gradual weight loss with a change in habits is saturated fatty acids and less than 300 milli-
much healthier and more likely to be sustained. grams of cholesterol daily
For example, a person never exercises but knows
that it is important. Initially, the person may walk ♦ Keep daily total fat intake to between 20 and
at a slow pace for 15 minutes every day. Gradually, 35 percent of calories consumed
the time and rate can be increased until the per- ♦ Select lean, low-fat, or fat-free foods whenever
son is walking at a brisk pace for 30 minutes 5 days possible
a week. At the same time that exercise increases, ♦ Eat more fiber-rich fruits, vegetables, and
the number of calories consumed must change. whole grains
Before starting any weight management plan,
a physician should be consulted. The physician ♦ Limit foods high in sugar and salt
may perform a physical examination, order blood Following these recommendations can help an
or other laboratory tests to check for diseases that individual obtain and maintain a healthy weight.
could affect weight, run an electrocardiogram, This will help reduce the risk factor for heart dis-
and/or order a stress test to determine cardiovas- ease, hypertension, diabetes mellitus, high cho-
cular fitness. The physician can then recommend lesterol, osteoarthritis, and many other diseases.
a nutrition plan and exercise program that is cus- It will also allow the individual to enjoy a longer
tomized to the individual’s needs. and healthier life span.
A general guideline for weight loss or gain is
that 1 pound of body fat equals approxi-
mately 3,500 calories. To lose 1 pound, a decrease
of 3,500 calories is required, either by consuming 11:6 Information
3,500 fewer calories or by using 3,500 calories
through increased exercise. To gain 1 pound, an
Therapeutic Diets
increase of 3,500 calories is required. A general Therapeutic diets are modifications of the nor-
guideline to maintain weight is that a person mal diet and are used to improve specific health
consume 15 calories per pound per day. For conditions. They are normally prescribed by a
example, if a person weighs 120 pounds, main- doctor and planned by a dietitian. These diets
taining this weight would require a daily intake of may change the nutrients, caloric content, and/
15 120, or 1,800, calories daily. By decreasing or texture of the normal diet. They may seem
caloric intake by 500 calories per day, a person strange and even unpleasant to patients. In addi-
would lose 1 pound per week (500 calories per tion, a patient’s appetite may be affected by
day times 7 days equals 3,500 calories, or 1 pound anorexia (loss of appetite), weakness, illness,
of fat). By increasing caloric intake by 500 calo- loneliness, self-pity, and other factors. Therefore,
ries per day, a person would gain 1 pound per it is essential that the health care worker use
week. It is important to note that increasing or patience and tact to convince the patient to eat
decreasing exercise along with controlling calorie the foods on the diet. An understanding of the
intake is essential. Also, a slow, steady gain or loss purposes of the various diets will also help the
of 1–2 pounds per week is an efficient and safe health care worker provide simple explanations
form of weight control. to patients.
310 CHAPTER 11
REGULAR DIET SOFT DIET

A regular diet is a balanced diet usually used for A soft diet is similar to the regular diet, but foods
the patient with no dietary restrictions. At times, it must require little chewing and be easy to digest
has a slightly reduced calorie content. Foods such (figure 11-7). Foods to avoid include meat and
as rich desserts, cream sauces, salad dressings, shellfish with tough connective tissue, coarse
and fried foods may be decreased or omitted. cereals, spicy foods, rich desserts, fried foods, raw
fruits and vegetables, nuts, and coconut. This diet
may be used following surgery or for patients
LIQUID DIETS with infections, digestive disorders, or chewing
problems.
Liquid diets include both clear liquids and full
liquids. Both are nutritionally inadequate and
should be used only for short periods of time. All
foods served must be liquid at body temperature.
DIABETIC DIET
Foods included on the clear-liquid diet are mainly A diabetic diet is used for patients with diabe-
carbohydrates and water, including apple or tes mellitus. In this condition, the body does not
grape juice, fat-free broths, plain gelatin, fruit ice, produce enough of the hormone insulin to
ginger ale, and tea or black coffee with sugar (fig- metabolize carbohydrates. Patients frequently
ure 11-6). The full-liquid diet includes the liquids take insulin by injection. The diet contains
allowed on the clear-liquid diet plus strained exchange lists that group foods according to type,
soups and cereals, fruit and vegetable juices, nutrients, and caloric content. Patients are
yogurt, hot cocoa, custard, ice cream, pudding, allowed a certain number of items from each
sherbet, and eggnog. These diets may be used exchange list according to their individual needs.
after surgery, for patients with acute infections or Sugar-heavy foods such as candy, soft drinks,
digestive problems, to replace fluids lost by vom- desserts, cookies, syrup, honey, condensed milk,
iting or diarrhea, and before some X-rays of the chewing gum, and jams and jellies are usually
digestive tract. avoided.
FIGURE 11-6 Foods included on the clear-liquid FIGURE 11-7 Soft diets include foods that require
diet are mainly carbohydrates and water. little chewing and are easy to digest.
Patients should avoid or limit adding salt to food,

CALORIE-CONTROLLED smoked meats or fish, processed foods, pickles,
DIETS olives, sauerkraut, and some processed cheeses.
This diet reduces salt intake for patients with car-
Calorie-controlled diets include both low- diovascular diseases (such as hypertension or
calorie and high-calorie diets. Low-calorie diets congestive heart failure), kidney disease, and
are frequently used for patients who are over- edema (retention of fluids).
weight. High-calorie foods are either avoided or
very limited. Examples of such foods include but-
ter, cream, whole milk, cream soups or gravies, PROTEIN DIETS
sweet soft drinks, alcoholic beverages, salad dress- Protein diets include both low-protein and
ings, fatty meats, candy, and rich desserts. High- high-protein diets. Protein-rich foods include
calorie diets are used for patients who are meats, fish, milk, cheeses, and eggs. These foods
underweight or have anorexia nervosa, hyperthy- would be limited or decreased in low-protein
roidism (overactivity of thyroid gland), or cancer. diets and increased in high-protein diets. Low-
Extra proteins and carbohydrates are included. protein diets are ordered for patients with certain
High-bulk foods such as green salads, watermelon, kidney or renal diseases and certain allergic con-
and fibrous fruits are avoided because they fill up ditions. High-protein diets may be ordered for
the patient too soon. High-fat foods such as fried children and adolescents, if growth is delayed; for
foods, rich pastries, and cheese cake are avoided pregnant or lactating (milk-producing) women;
because they digest slowly and spoil the appetite. before and/or after surgery; and for patients suf-
fering from burns, fevers, or infections.
LOW-CHOLESTEROL
DIET BLAND DIET
A low-cholesterol diet restricts foods that con- A bland diet consists of easily digested foods
tain cholesterol. It is used for patients with ath- that do not irritate the digestive tract. Foods to be
erosclerosis and heart disease. Foods high in avoided include coarse foods, fried foods, highly
saturated fat, such as beef, liver, pork, lamb, egg seasoned foods, pastries, candies, raw fruits and
yolk, cream cheese, natural cheeses, shellfish vegetables, alcoholic and carbonated beverages,
(crab, shrimp, lobster), and whole milk, are lim- smoked and salted meats or fish, nuts, olives,
ited, as are coconut and palm oil products. avocados, coconut, whole-grain breads and cere-
als, and usually, coffee and tea. It is used for
patients with ulcers, colitis, and other diseases of
FAT-RESTRICTED DIETS the digestive system.
Fat-restricted diets are also called low-fat diets.

Examples of foods to avoid include cream, whole LOW-RESIDUE DIET
milk, cheeses, fats, fatty meats, rich desserts,
chocolate, nuts, coconut, fried foods, and salad A low-residue diet eliminates or limits foods
dressings. Fat-restricted diets may be used for that are high in bulk and fiber. Examples of such
obese patients or patients with gallbladder and foods include raw fruits and vegetables, whole-
liver disease or atherosclerosis. grain breads and cereals, nuts, seeds, beans, peas,
coconut, and fried foods. It is used for patients
with digestive and rectal diseases, such as colitis
SODIUM-RESTRICTED or diarrhea.
DIETS
Sodium-restricted diets are also called low-
OTHER DIETS
sodium or low-salt diets. Frequently, patients use Other therapeutic diets that restrict or increase
low-sodium-diet lists similar to the carbohy- certain nutrients may also be ordered. The health
drate-exchange lists used by diabetic patients. care worker should always check the prescribed
312 CHAPTER 11

A daily pill that prevents heart attacks and strokes?
Heart disease is the main cause of death in the United States. The American Heart Asso-
ciation estimates that in the United States alone, 70.1 million people have some form of
cardiovascular (heart and blood vessel) disease. Each year more than 1 million people have
a heart attack. More than 800,000 people die of heart disease. Stroke is the third largest cause
of death in the United States. Each year about 700,000 people have a stroke; of these, almost
275,000 die.
In Europe, researchers are evaluating a pill that will reduce heart attacks and strokes by
almost 80 percent. It has been called a “super vitamin” because it is a once-daily pill. The pill
contains six different types of medicines: aspirin, a cholesterol-lowering drug, three blood
pressure–lowering drugs, and folic acid. Aspirin is used to regulate the level of platelets
(blood cells that aid in the clotting of blood). Cholesterol is a type of fat found in animal
products. Its presence in high amounts can cause fatty deposits on the walls of blood ves-
sels. The three blood pressure–lowering drugs are used in small amounts, but each has a
different way to reduce blood pressure. Folic acid, a vitamin, is used to reduce the amount
of a protein that may contribute to blocked arteries.
The current problem is to ensure that all of the combined ingredients do not cause other
chemical reactions. The drug must be stable over a period of time, and care must be taken
so that the products do not break down or deteriorate. Researchers are also experimenting
with the “ideal” amount of each ingredient. It may even be necessary to create “super pills”
with different amounts of the six ingredients to account for individual differences. However,
if these problems can be solved, people could stay much healthier by taking one “super vita-
min” each day. Thousands of lives could be saved each year through the prevention of heart
attacks and strokes.
diet and ask questions if foods seem incorrect. Daily food intake should provide an individual
Every effort should be made to include foods the with proper amounts of the essential nutrients.
patient likes if they are allowed on a particular Before the body can obtain the essential nu-
diet. If a patient will not eat the foods on a pre- trients from food, the body must digest the food.
scribed therapeutic diet, the diet will not contrib- After digestion, the nutrients are absorbed and
ute to good nutrition. carried by the circulatory system to every cell in
the body. Metabolism then occurs, and the nu-
STUDENT: Go to the workbook and complete trients are used by cells for body functions.
the assignment sheet for Chapter 11, Nutrition The simplest guide for planning healthy
and Diets. meals that provide the required essential nu-
trients is to eat a variety of foods from the five
major food groups. Portion sizes should vary ac-
CHAPTER 11 SUMMARY cording to the individual’s caloric requirements.
Maintaining healthy weight, choosing foods low
in fat, using sugar and salt in moderation, and
An understanding of basic nutrition is essential limiting alcoholic beverages are also important
for health care workers. Good nutrition helps aspects of proper nutrition.
maintain wellness, a state of good health with Weight management is used to achieve and
optimal body function. maintain the desired body weight. The major
Essential nutrients are used by the body to conditions that occur because of poor nutrition
perform many different functions. There are six and improper exercise are underweight, over-
groups of essential nutrients: carbohydrates, weight, and obesity. Careful control of caloric
fats, proteins, vitamins, minerals, and water. intake and regular physical exercise are the key
methods for obtaining and maintaining normal 7. Therapeutic diets: determine foods allowed or
weight, or body weight that is in proportion to foods that must be avoided in diabetic, calorie-
body height. Good weight management reduces controlled, low-cholesterol, fat-restricted,
the risk factor for many diseases and allows an sodium-restricted, low-residue, bland, and
individual to enjoy a longer and healthier life high- or low-protein diets
span.
Therapeutic diets are modifications of the
normal diet. They are used to improve specific REVIEW QUESTIONS
health conditions. Examples of therapeutic diets
include liquid, diabetic, calorie-controlled, low- 1. List the six (6) essential nutrients and the main
cholesterol, fat- or sodium-restricted, high- or function of each nutrient.
low-protein, and bland diets. An understanding
of these diets will allow the health care worker to 2. Differentiate between digestion, absorption,
encourage patients to follow prescribed diets. and metabolism.
3. What is BMR?
INTERNET SEARCHES 4. List all of the foods you have eaten today. Be
sure to include all snacks. Compare your list
Use the suggested search engines in Chapter 12:4 with the recommended daily intake of various
of this textbook to search the Internet for addi- foods from My Pyramid. Is your diet adequate
tional information on the following topics: or deficient? Explain why.
1. Nutritional status: search words such as 5. Differentiate between overweight and obesity.
nutrition, diet, and nutritional status List six (6) conditions that can develop as a
result of obesity.
2. Diseases: search for more detailed information
on nutritional diseases such as hypertension, 6. What is BMI? Calculate your BMI.
atherosclerosis, osteoporosis, and malnutrition 7. Calculate the number of calories you require
3. Essential nutrients: search for information on per day to maintain your present weight. How
daily nutritional requirements for nutrients many calories should you ingest per day to
such as carbohydrates, proteins, lipids or fats, gain one pound per week? How many calories
vitamins, and minerals should you ingest per day to lose one pound
per week?
4. Utilization of nutrients: search for information
on the processes of digestion, absorption, and 8. Identify the type of therapeutic diet that may
metabolism be ordered for patients with the following
conditions:
5. Food energy: use words such as weight loss, a. gallbladder or liver disease
weight gain, and diet to learn more about b. diabetes mellitus
weight control by proper nutrition c. hypertension or heart disease
6. Organizations: obtain additional information d. ulcers, colitis, or diseases of the digestive
on nutrition from organizations such as the tract
U.S. Department of Agriculture and the e. pregnant or lactating women
American Dietetic Association f. severe nausea, vomiting, and/or diarrhea
CHAPTER 12 Computer
Technology in
Health Care
Chapter Objectives
Observe Standard
Precautions
◆ Identify the three major components of a
computer system
◆ Compare computer capabilities and
limitations
◆ Describe computer applications currently
being used in today’s health care computer
Caution
systems
◆ Search the Internet for information on a
specific topic
on Federal Law ◆ Identify precautions that must be taken to
maintain the confidentiality of patient
information
Math Skill
◆ Differentiate between antivirus and firewall
software, and explain how each helps to
provide computer security
Science Skill
Career Information
Technology
Computer Technology in Health Care 315
KEY TERMS
browser input (pahs⬘-ih⬘-tron ee-miss⬘-
central processing unit interactive video (computer- shun toe-mawg⬘-rah-fee)
(CPU) assisted video) random access memory
computer literacy (come- Internet (RAM)
pew⬘-tur lit⬘-er-ass-see) magnetic resonance imaging read only memory (ROM)
computer-assisted (MRI) (mag-net⬘-ik rez⬘- record
instruction (CAI) oh-nance im⬘-adj-ing) software
computerized tomography mainframe computer spreadsheet
(CT) (com-pew⬘-tur-eyesd microcomputer stress test
toe-mawg⬘-rah-fee) modem telemedicine
database networks telepharmacies
echocardiograph output ultrasonography (ul-trah-
electronic mail personal computer sawn-ahg⬘-rah-fee)
fields positron emission
hardware tomography (PET)
12:1 INFORMATION tomography (CT scan), magnetic resonance

imaging (MRI), positron emission tomogra-
Introduction phy (PET), and ultrasonography
Computer technology has been called the great- ♦ Educational tools: computer-assisted instruc-
est advance in information processing since tion (CAI) and computer-assisted video
Gutenberg invented the printing press. The rapid instruction (interactive video) for professional
advances in health care and the explosion of nurses, physicians, and other allied health
information needed for health care workers to personnel
provide quality patient care have made the use of ♦ Research: statistical analysis of data
the computer a necessity. Today, it is as common
to see a computer terminal in the admissions It is estimated that the health care industry
office of your local hospital or clinic as it is to see will spend approximately one billion dollars on
a bar code reader being used to add up a grocery computer technology within the next few years.
bill in your neighborhood supermarket. In fact, Whether you want to be a physician, registered
many hospitals use this same bar coding method nurse, lab technician, nurse’s aide, radiology
to control inventories and patient costs for hos- technician, dietitian, pharmacist, occupational
pital supplies. therapist, physical therapist, or any other type
The computer has become essential in almost of allied health professional, a working knowl-
every aspect of health care. Computers are used edge of the computer is essential. This work-
in four general areas: ing knowledge is sometimes called computer
literacy. Computer literacy means a basic
♦ Hospital information systems (HIS) or medical understanding of how the computer works and a
information systems (MIS): managing budgets, basic understanding of the applications used in
equipment inventories, patient information, your field or profession. Computer literacy also
laboratory reports, operating room and per- means feeling comfortable using a computer for
sonnel scheduling, and general records your job needs. Practice and experience in using
♦ Diagnostic testing: analyzing blood and scan- a computer are essential in order to develop com-
ning or viewing body parts by computerized puter literacy.
316 CHAPTER 12
HISTORY OF THE 12:2 INFORMATION

COMPUTER What Is a Computer System?
The first computers were installed in hospitals in A computer system is an electronic device that
the late 1950s and early 1960s. Some of these hos- can be thought of as a complete information-
pitals had some form of assistance from the Inter- processing center. It can calculate, store, sort,
national Business Machines (IBM) Corporation. update, manipulate, sequence, organize, and
Today’s computers have come a long way process data. It also controls logic operations and
from the Electronic Numerical Integrator and can rapidly communicate in graphics, numbers,
Computer (ENIAC) built in 1946 by J. P. Eckert words, and sound.
and J. W. Mauchly at the University of Pennsylva-
nia. This huge computer had to be housed in a
room that measured 20 by 40 feet. The ENIAC
contained approximately 18,000 vacuum tubes.
COMPONENTS OF A
With the invention of the silicon chip in the 1970s, COMPUTER SYSTEM
hundreds of thousands of electronic components
were able to fit on a single chip smaller than a fin- All computer systems contain essentially the
gernail. These microchips paved the way for the same parts, the hardware and the software. The
introduction of the microcomputer. hardware consists of the machine components,
Computer chips are found in many com- including the keyboard, central processing unit
monly used items such as watches, cameras, tele- (CPU), disk drive, and monitor with display
phones, thermometers, blood pressure gauges, screen. The software consists of the programs,
cars, satellite navigation equipment, stoves, bur- or instructions, that run the hardware and allow
glar alarm systems, and personal desktop com- the computer to perform specific tasks.
puters. There are three major components to a com-
Computers vary in size. Computer size can puter system (figure 12-2):
range anywhere from a microcomputer such ♦ Input: information that is entered into the
as a handheld calculator or personal digital assis- computer by means of an input device
tant (PDA), which can be held in one hand, to a
♦ Central processing unit (CPU): processes
laptop in a compact case (figure 12-1), to a per-
the input and performs the operations of the
sonal computer, which can sit on a desktop, to
computer by following the instructions in the
a very large mainframe computer, which can
software
control the launching of a rocket to outer space.
♦ Output: the processed information, or final
product; it can be displayed on a screen,
printed as hard copy, stored on magnetic tape
or disks, or transmitted to another user or
users
Input Devices
For the computer to work, instructions and data,
or input, must be entered into it using some form
of input device. One of the most popular input
devices is the computer keyboard. This device is
similar to the familiar typewriter keyboard. Other
input devices include:
♦ Magnetic tape: usually used to enter data on
large, mainframe computers
FIGURE 12-1 Today’s microcomputers fit easily ♦ Touch screen monitor: a monitor with touch-
on a lap or desktop. sensitive areas built into the screen; examples
Software Output Devices
Input Devices Monitor
Mouse
Printer
Keyboard
Modem
Optical Disk
Scanner
Central Processing Unit

Data Storage Device
FIGURE 12-2 Components of a computer system.

are the touch screens found in many fast-food computer. The CPU is divided into three main
outlets and on many microwave ovens units: the internal memory unit, the arithmetic
♦ Optical scanner: a machine that can scan a and logic unit, and the control unit (figure 12-4).
document and read the printed text; an exam- ♦ Internal memory unit: This unit is controlled
ple is the bar code readers found in many by two types of memory. A permanent pro-
supermarkets and used to record and total gram already built and stored in the computer
grocery items
♦ Mouse: a small device that sits on a desktop or
is built into the keyboard of a laptop com-
puter; it controls the cursor and performs
other functions such as creating graphics
♦ Light pen: a device that looks like a pen and is
used to perform functions such as selecting
menus and drawing graphics on a cathode ray
tube, or CRT, which is similar to a television
screen (figure 12-3)
Central Processing Unit

The CPU processes all information or data enter- FIGURE 12-3 The light pen is a common input
ing the computer. It acts as the “brain” of the device. (Courtesy of USDA/ARS #K-2656-2)
318 CHAPTER 12
INPUT
DEVICE
CENTRAL PROCESSING UNIT (CPU)
CONTROL UNIT ARITHMETIC AND LOGIC UNIT

1. ACCESSES PROGRAMS 1. CONDUCTS FUNCTION
FROM MEMORY
2. DIRECTS DATA FLOW 2. COMPARES DATA
3. CONTROLS PERIPHERAL 3. PERFORMS OPERATIONS

UNITS & WORK FLOW
INTERNAL MEMORY UNIT

1. STORES OPERATING PROGRAMS
2. STORES TEMPORARY DATA
3. STORES MONITORING & TRACKING DATA
EXTERNAL OUTPUT
MEMORY UNIT DEVICE
FIGURE 12-4 The central processing unit (CPU) is the “brain” of the computer.
system by the manufacturer of the computer

is called read only memory (ROM). A pro-
gram that is NOT permanent because data can
be stored, changed, and/or retrieved is called
random access memory (RAM), or read/
write memory.
♦ Arithmetic and logic unit (ALU): This performs
all of the calculations, such as addition, sub-
traction, multiplication, and division. It also
provides for a logical, step-by-step handling of
data or information as the data or information
enters or leaves the computer.
♦ Control unit: This unit communicates with
the input and output units of the computer
system. It initiates, interprets, directs, and
controls the processing of information.
Output Devices FIGURE 12-5 The printer is a common output

Output is the finished work of the computer. Out- device that produces a paper printout called hard
put occurs after the data have been processed by copy. (Courtesy of Photodisc)
the CPU. The most common output devices are
the printer (figure 12-5), which is similar to a can also appear on a computer monitor display
typewriter, and the video display monitor, such screen. Data can be stored or transferred to mag-
as the cathode-ray tube (CRT) or flat-screen netic tapes, disks, CDs, DVDs, or flash (travel)
monitor. drives. Data can also be displayed on a video
Output can take the form of a hard copy monitor or heard as music or sound through an
(paper printout) from a printer or plotter. Output audio speaker.
12:3 INFORMATION
Computer Applications
INFORMATION SYSTEMS
Computers were first introduced into hospitals to
simplify accounting procedures such as payrolls
and inventories. The introduction of computers
saved both money and time. Today’s health care
providers use computers in every health care
facility. Computers are used for:
♦ Word processing: This includes writing letters, FIGURE 12-6 Computers are used to monitor
memos, reports, policies, and procedures; cre- fetal movements.
ating patient care plans; and documenting
care on a patient’s record. Documents created
blood tests, urine tests, and cardiac and respi-
by word processing software can be edited
ratory functions.
and corrected, stored for future use, and
printed or sent by electronic mail or fax. ♦ Maintaining inventories: Inventory mainte-
nance includes ordering and tracking supplies
♦ Compiling databases: This includes creating
and equipment, and coding supplies with bar
information records for patients and employ-
codes for billing purposes.
ees. A database is an organized collection of
information. Information is entered into areas ♦ Developing spreadsheets: A spreadsheet uses
called fields. For example, the database may special software to access a computer’s ability
contain information such as name, address, to perform high-speed math calculations. The
telephone, insurance information, social secu- user enters formulas to tell the computer to
rity number, place of employment, and medical perform specific math functions (addition,
history. Each type of information is a field. subtraction, multiplication, division, percent-
Within the database, each collection of related age) with numerical data. This allows the user
information is called a record. For example, to process bills, maintain accounts, create
when all of the fields for a particular patient are budgets, develop statistical reports, analyze
combined, the information on the patient is the finances, tabulate nutritional value of foods,
record. All records can be edited and corrected, evaluate treatments, and project future needs.
stored for future use, and printed or sent by In addition, once a spreadsheet has been cre-
e-mail or fax. Most databases that contain ated, the numerical data and statistics can be
patient records are access limited or password displayed as a graph or chart (figure 12-7).
protected to maintain patient confidentiality. ♦ Communicating: Communicating involves
♦ Scheduling: Scheduling is recording appoint- using modems or high-speed data transmis-
ments for patients and creating work sched- sion networks to communicate with other
ules for employees. departments or different facilities, send or
♦ Maintaining financial records: This includes receive information by e-mail, order supplies
processing charges, billing patients, recording or equipment, and operate security systems.
payments, completing insurance forms, main- When a patient is admitted to a hospital,
taining accounts, and calculating payrolls for many different health care providers use com-
employees. puters to record the patient’s information. Some
♦ Monitoring patients: This includes recording examples include:
heart rhythms, pulse, blood pressure, blood ♦ Health information technician (admissions
oxygen levels, and fetal movements (figure technician): obtains the patient’s name, age,
12-6). and all other vital information to enter, pro-
♦ Performing diagnostic tests: Diagnostic tests cess, and store in the computer’s memory;
include radiological imaging (CT, PET, MRI), establishes an electronic database so that the
320 CHAPTER 12
Industrial Injuries by Part Affected
Finger
Back
Average Number of Patients Eyes
Seen per Day in a Group Practice
Other
140
130
120
110
100
90
80 Ages of Patients in a Cardiac Practice
25
70
60 20
Percent of Patients Male
50
40 Female
15
30
20 10
10
5
0
J F M A M J J A S O N D
0
Month 0-8 9-16 17-24 25-32 33-40 41-48 49-54 55-62 63-70 70+
FIGURE 12-7 The numerical data and statistics on a spreadsheet can be displayed as graphs or charts.
information about the patient can be retrieved ♦ Environmental service worker (central supply/
whenever it is needed central processing worker): maintains an
♦ Physician: uses word processing to enter all inventory of all supplies in the facility, orders
the findings of the initial admitting physical required supplies, and provides information
examination; order all of the patient’s medica- for billing supplies. Many facilities use bar
tions from the pharmacy; order laboratory codes on each supply item. When the item is
tests, including blood and urine studies; and/ used for a particular patient, the bar code is
or order an electrocardiogram, radiographs, scanned into the patient’s record for auto-
dietary restrictions, and specific nursing care matic billing to the patient.
♦ Pharmacist: checks the computer regularly
for new orders; supplies the nursing depart- After each health care worker inputs informa-
ments with ordered medications; warns phy- tion into the patient’s record, the information is
sicians of drug interactions; and monitors then immediately accessible to the medical, nurs-
pharmacy inventory (figure 12-8) ing, and allied health teams. These teams no lon-
ger have to wait for the results of tests to be typed
♦ Dietitian: checks the dietary restrictions and on a typewriter and hand delivered to the patient
creates a spreadsheet to show a nutritional care area. Nurses no longer have to manually
analysis of the prescribed diet transcribe physicians’ orders or nurses’ notes.
♦ Laboratory technician: checks the computers Because patient care plans are computerized,
for new or revised orders; when any test or they can be easily updated. This use of the com-
procedure is completed, records the results in puter decreases the time health care workers
the patient’s computerized record spend on paperwork and away from patient care.
insurance companies, pharmacies, and other

health care facilities that would require the infor-
mation. Massive filing systems with tons of paper
charts would no longer be required. Safeguards
would have to be installed in the computer, how-
ever, to meet Health Insurance Portability and
Accountability Act (HIPAA) requirements (dis-
cussed in Chapters 5:1 and 12:5) and protect the
privacy of patient information.
Confidentiality of patient information must
be strictly enforced. This is usually done by
means of access codes or special passwords.
Computer users must enter the special access
code or password to enter or retrieve informa-
tion. Only authorized workers are given access to
the system. Health care workers must keep their
code or password confidential to protect them-
selves and the patient.
A contingency backup plan is always essen-
tial when computers are used. At times, a com-
puter must be shut down for reprogramming or
adding additional or new software. At other times,
power or computer failure will shut down the
computer system. When the computer is not
functioning, manual recording of all information
is required and an alternative plan must be used
to avoid losing essential information. Most facili-
ties make frequent backup tapes or disks to pre-
FIGURE 12-8 Pharmacists can use the computer vent a loss of information when computer failure
to monitor medications and maintain inventories. occurs.
(Courtesy of USDA/ARS #K-3512-3)
Many health care facilities are using bar codes

on patient identification bands. Small scanners
DIAGNOSTICS
are used to scan the band and verify that a treat- The major goal of health care and medicine is
ment or medication is being given to the correct determining exactly what is wrong with the
patient. The bar codes are extremely useful for patient. The first step in the process is taking a
disoriented or unconscious patients. medical history and doing a physical examina-
Hand-held portable computers are used in tion. Based on these findings, several tests may
many hospitals. The terminal device contains a be ordered to diagnose or rule out disease.
miniature keyboard and is linked remotely to the Several computer-related diagnostic tests
nurse’s station. With this small terminal, the have had a real impact on patient care. These
health care worker is able to record data at a diagnostic aids or specialized technological tools
patient’s bedside. Patient information, such as are quite varied. They may be invasive, such as a
temperature, heart rate, and respirations, is blood test where a syringe is inserted into a vein
recorded and immediately available to other and blood is removed, or noninvasive, such as an
health care providers. Updated data are also imaging procedure where no opening into the
received from other parts of the hospital. Other body is required.
health care workers can then retrieve this infor- Some computerized instruments automate
mation from the computer. the step-by-step manual procedure of analyzing
Eventually, this may lead to a “paperless” blood, urine, serum, and other body-fluid sam-
patient record. All information would be stored ples. Most laboratories rely heavily on computers
in a computer database and sent electronically to for both blood and urine analysis. Smaller units
322 CHAPTER 12
are now used in many medical offices and other

health care facilities. The computerized instru-
ments can analyze a drop of serum, blood, urine,
or body fluid placed on a slide at rates of over 500
specimens an hour. Such systems have proved to
be reliable for clinical chemistry evaluations.
An electrocardiogram (ECG) computerized
interpretation system produces visual pictures
on a computer monitor and a printout of the
electrical activity of a patient’s heart. The ECG
gives important information concerning the
spread of electrical impulses to the heart cham-
bers. It is very important in diagnosing heart dis-
ease. An ECG run while the patient is exercising is
known as a stress test (figure 12-9). This allows
the physician to evaluate the function of the
patient’s heart during activity. An echocardio-
graph utilizes a computer to direct ultrahigh-
frequency sound waves through the chest wall
and into the heart (figure 12-10). The computer
then converts the reflection of the waves into an
image of the heart. This test can be used to evalu-
ate cardiac function, reveal valve irregularities,
show defects in the heart walls, and visualize the
presence of fluid between the layers of the peri-
cardium (membrane that surrounds the outside
of the heart). Computers are also used to monitor
a patient’s pulse and to determine the oxygen FIGURE 12-10 An echocardiograph utilizes a
level in the blood (figure 12-11). computer to evaluate cardiac function, reveal heart
valve irregularity, and show defects or diseases of
the heart.
FIGURE 12-11 Pulse oximeters use computer

technology to monitor a patient’s pulse and deter-
mine the oxygen level in the blood.
One advance in medical imaging is the com-

FIGURE 12-9 Computers are used to perform puterized tomography (CT) scanner, intro-
stress tests to evaluate the function of a patient’s duced in 1972. The CT scanner was the first
heart during exercise. (Courtesy of Spacelabs computer-based body and brain scanner. This
Medical Inc.) noninvasive, computerized X-ray permits physi-
cians to see clear, cross-sectional views of both

bone and body tissues and to find abnormalities
such as tumors (figure 12-12). The CT scanner
shoots a pencil-thin beam of X-rays through any
part of the body and from many different angles.
The computer then creates a cross-sectional
image of the body part on a screen. A CT scan
provides a clear image of the soft tissues inside
the body and exposes the patient to less radiation
than a conventional radiograph. In addition, a
regular radiograph shows little depth, and the
soft tissue does not appear clearly.
Another powerful advance in medical imag-
ing is magnetic resonance imaging (MRI).
This computerized, body-scanning method uses
nuclear magnetic resonance instead of X-ray
FIGURE 12-13 For magnetic resonance imaging
radiation. Magnetic resonance imaging is the (MRI), the patient is placed in the center of a large
alteration of the magnetic position of hydrogen magnet that measures the activity of hydrogen ions
atoms to produce an image. The patient is placed inside the body and creates an image of the body.
in a large circular magnet, which uses the mag- (Courtesy of GE Medical Systems)
netic field to measure activity of hydrogen atoms
within the body (figure 12-13). A computer trans-
lates that activity into cross-sectional images of
the body (figure 12-14). For example, a lung tumor
can be more easily detected by scanning with
MRI than by scanning with X-rays or CT. Mag-
netic resonance imaging allows physicians to see
blood moving through veins and arteries, to see a
swollen joint shrink in response to medication,
and to see the reaction of cancerous tumors to
treatment.
Positron emission tomography (PET) is
another scanning procedure. A slightly radioac-
tive substance is injected into the patient and
FIGURE 12-14 This magnetic resonance imaging

(MRI) scan shows a coronal image of the abdomen.
detected by the PET scanner. The device’s com-

puter then composes a three-dimensional image
from the radiation detected. The image allows
the doctor to see an organ or bone from all sides.
In this way, a PET image is similar to a model that
FIGURE 12-12 This computerized tomography can be picked up and examined.
(CT) scan highlights the blood vessels of the liver, Ultrasonography (figure 12-15) is another
heart, and spleen. noninvasive scanning method. It uses high-
324 CHAPTER 12
colored picture similar to a portrait of the infant

in the uterus. Physicians use the 3-D ultrasound
to detect birth defects that are not always visible
on a standard sonogram and to determine the
severity of a birth defect.
Computers play a major role in oncology
(malignancy or cancer) radiology departments.
Computers are used to convert information from
various scanners to exact data on the location of
a tumor. The computer then directs the power of
therapeutic radiation precisely to the tumor
being irradiated.
FIGURE 12-15 Ultrasonography is used during

pregnancy to determine the size, position, sex, and
even abnormalities of the fetus. EDUCATION
Computers have become commonplace as edu-
frequency sound waves that bounce back as an cational tools. They can be found in elementary,
echo when they hit different tissues and organs middle, junior high, and high schools, in addition
inside the body. A computer then uses the sound to post-secondary education institutions, such as
wave signals to create a picture of the body part, colleges and universities. Research has shown
which can be viewed on a computer screen or that computer-based learning decreases time on
processed on a photographic film that resembles the task and increases achievement and reten-
a radiograph. Ultrasonography can be used to tion of knowledge. Therefore, it comes as no sur-
detect tumors, locate aneurysms and blood prise to find computer-based learning in most
vessel abnormalities, and examine the shape schools of medicine, nursing, and allied health.
and size of internal organs. During pregnancy, Computer-assisted instruction (CAI) is
when radiation can harm the fetus, ultrasonogra- educational computer programming designed
phy is used to detect multiple pregnancies and for individualized use. It is user paced, user
to determine the size, position, sex, and even friendly, and proceeds in an orderly, organized
abnormalities of the fetus (figure 12-16). A more fashion from topic to topic. It may use animated
recent development in sonography is the three- graphics, color, and sound. It may be a drill-and-
dimensional (3-D) sonogram. This type of ultra- practice program for learning to calculate medi-
sound uses a specialized machine that allows cation doses, or may take the form of a tutorial
technicians to store 5 seconds’ worth of images in for learning concepts about the heart. In addi-
a computer. The technician can then create a 3-D tion, it can be a simulation that allows the learner
to do a clinical procedure, such as taking a
patient’s blood pressure or drawing blood from a
vein (venipuncture), while sitting in front of the
computer. Computer programs have even been
developed to allow a user to perform a simulated
operation on a patient.
Patient-education software is available for
the patient with osteoarthritis (inflammation of
the joints), obesity (overweight), and many other
diseases. Software is even available to teach peo-
ple how to manage stress.
Another advance in computer learning tech-
nology is interactive video, or computer-
assisted video. Interactive video is the
integration of computer and video technology. It
FIGURE 12-16 This ultrasound shows the fetus combines the advantages of video (color, sound,
inside the uterus. (Courtesy of Sandy Clark) and motion) with the advantages of computer-
assisted instruction to provide a dynamic new others help the user learn how to use the program
learning medium. Research has shown that this in a step-by-step fashion.
technology greatly enhances learning and reten- Research using computer technology is being
tion. Programs available include those that teach conducted for almost every disease, infection, or
medical terminology to health care workers, clin- abnormal health condition that exists. Examples
ical skills to nurses, physical examination tech- include genetic diseases, heart conditions, dia-
niques to physicians, and anatomy and physiology betes, arthritis, patient management systems,
to students. Programs are stored on compact and speech recognition patterns. Information
disks or CD-ROMs that are inserted into a video- acquired during research is frequently organized
disc player. into large databases and shared with other
The Internet offers a new approach to educa- researchers throughout the world. This process,
tion called distance learning. Students can access known as bioinformatics, allows for rapid scien-
a wide variety of courses over the Internet. This tific progress through the sharing of informa-
allows them to complete the courses in their own tion.
homes at times convenient to them. Many health In addition, clinical researchers are now using
care workers use the Internet to obtain continu- microcomputers for people who have had severe
ing education units (CEUs) or to complete college spinal cord injuries. The microcomputers are
courses to advance in their professions. Refresher used to initiate the electrical impulses that stim-
courses to prepare for licensure are also available ulate skeletal muscles. This exciting application
for many health care careers. Finally, many tests of computing was used to develop a computer-
for licensure are now taken on a computer. This controlled walking system. This system enables
allows for immediate grading of the licensure paraplegics and quadriplegics to stand, sit, and
examination. Examples include the licensure walk. Electrodes are applied above the hamstring,
tests for registered nurses and physicians. quadriceps, and gluteus maximus muscles. These
electrodes allow control of flexion and extension
of the knees and hips. Sensors applied to the knee
RESEARCH provide information to coordinate movement of
the knee when the patient is standing or walking.
Today, health care research without the use of Electrical impulses (controlled by the microcom-
computers is almost nonexistent. A major source puter) are delivered through these electrodes to
used to help health care professionals analyze stimulate the muscles through a preprogrammed
statistics and obtain information is the National series of exercises. The computer is programmed
Library of Medicine database, which is the largest to automatically stop the exercise program when
research library in the scientific community. It the sensors detect that the muscles have become
serves as a national resource for all U.S. health fatigued.
science libraries. It is located at the National
Institutes of Health in Bethesda, Maryland.
The library’s computer-based Medical Litera-
ture Analysis and Retrieval System (MEDLARS) is
COMMUNICATION
the major source of a bibliographic biomedical Computers have enhanced communication for
information database. It can be easily accessed health care workers in multiple ways. Through
by computer through the Regional Medical the use of systems called networks, computers
Library Network. The MEDLARS includes more can be linked together through cables and/or
than 40 databases, including Index Medicus, a telephone lines. A network can consist of three or
monthly subject/author guide to more than 3,500 four computers linked together in a medical or
journal articles, and Medline, which currently dental office, 100 computers linked together in a
contains more than 10 million references, as well large health care facility such as a hospital, or the
as information about audiovisual materials. ultimate networked system, the Internet, which
Statistical Package for the Social Sciences links millions of computers located throughout
(SPSS) is a program used in many universities to the world. Networks allow multiple users to share
prepare and analyze research data. Other pro- the same data or information at the same time.
grams score and analyze student test scores. They also allow rapid communication between
Some programs can draw graphs and charts, and individuals. Examples of using networks for com-
326 CHAPTER 12
munication include e-mail, telemedicine, tele- laboratory tests, or obtain financial information
pharmacies, and Listservs. about their account. In most cases, the physician
Electronic mail, or e-mail, is the process of and patient form a contract to use e-medicine.
creating and sending messages from one com- Most physicians do not charge for prescription
puter to another. It allows health care workers to renewals or information on billing or laboratory
quickly send messages, memos, announcements, results. However, physicians may charge for assist-
reports, and other data to one or more persons. ing with routine medical problems or evaluating
Attachments, such as files created in word- health information sent by patient monitors. The
processing programs, insurance forms completed term Web visit has been used to describe this
with insurance software, financial data compiled interaction between patient and physician. It
on spreadsheets, X-rays or radiographic images, allows physicians to handle routine medical prob-
and/or photographs, can be sent electronically. lems in a quick and efficient manner. If the
For example, all claims for Medicare and Medic- patient’s problems seem more complex, physi-
aid must be submitted electronically. The claim is cians can recommend an office visit.
usually completed on specialized insurance soft- Telepharmacies allow for rapid dispensing
ware, attached to an e-mail, and filed electroni- of medications. Prescriptions are sent electroni-
cally as a claim. Most insurance companies also cally to a computerized dispensing unit. The unit
use electronic filing for claims. Electronic mes- prepares and dispenses the ordered prescription,
sages should be created following the same pro- which is then mailed or sent by a carrier service
fessional standards for any written document. to the patient or health care facility.
The message should be clear and concise, correct Health care workers may also receive health
grammar and spelling must be used, and slang or information through Listserv mailing lists. These
codes should be avoided. It is also important for are automated systems that send e-mail mes-
all health care personnel to understand that all sages on specific topics, similar to receiving a
e-mail messages belong to the employer or owner newsletter or magazine. Some health care List-
of the computer. The messages may be stored in servs are free, while others charge monthly or
backup files and employers have the legal right annual fees.
to read and monitor any messages. Health care
personnel should never send or receive personal
e-mail correspondence at their place of employ- SUMMARY
ment.
Telemedicine, discussed in detail in Chap- Today, computers are used as cost-effective and
ter 1:2, involves the use of video, audio, and com- efficient tools to enhance quality patient care.
puter systems to provide medical and/or health They are used to analyze blood; regulate electri-
care services. For example, X-rays or electrocar- cal impulses to muscles; take pictures of the body;
diograms can be transmitted electronically from collect patient data; analyze electrocardiograms;
one physician to another for consultation. A sur- schedule hospital personnel; keep hospital and
geon can direct the work of another surgeon, or clinic records, inventories, and budgets; and pro-
even a robotic arm, by watching the procedure vide information on wellness to the general pub-
on video. Telemedicine also allows patients to lic. Computer technology has truly invaded the
communicate with physicians or health care spe- health care field.
cialists at a distance, transmit medical informa-
tion to a physician, or be monitored by health
care professionals. A recent advance in telemedi- 12:4 INFORMATION
cine is a computerized device that has sensors
that remind a patient to take medications at spe-
Using the Internet
cific times and a touchscreen medicine cabinet A network of computer users can be found on the
that recognizes faces and can determine that the Internet. Many types of services and sources of
patient is taking the correct medication. information are offered. Through the Internet,
E-medicine is another growing practice that health care professionals can readily contact oth-
allows patients to communicate with a physician ers for medical updates, information on new pro-
by e-mail to ask routine medical questions, ask for cedures, aid in making diagnoses, and many
renewals of prescriptions, obtain the results of other kinds of information.
Obtaining access to the Internet is not diffi- There are many different search engines
cult. Only four things are needed: a computer, a available to an Internet user. Many of them use
modem, a service provider, and a browser. A a variety of indexes or directories to provide
modem is an electronic device that sends or sources of information. In addition, different
receives computer data over telephone lines or search engines partner together to share index
cable. A service provider allows the user to con- listings. Some of the more popular search engines
nect to the Internet. Examples include dial-up, that provide dependable results, are constantly
DSL, cable, and wireless services. A browser is upgraded with new information, and are avail-
software that allows the user to access informa- able to all Internet users include:
tion on the Internet.
One major use of the Internet in health care ♦ All the Web (FAST search) (www.alltheweb.
relates to organ transplants. When an individual com): one of the largest indexes of the Web
needs a transplant, vital information regarding ♦ Alta Vista (www.altavista.com): one of the old-
the individual is recorded on the transplant net- est and largest crawler-based directories; also
work. The computer monitors all organs as they offers news search, shopping search, multi-
become available, and can immediately notify media search, and human-powered directory
the online facility when an organ is suitable for a results from other search engines
particular patient. This allows the most expedi- ♦ America On Line (AOL) (http://search.aol.com):
ent use of donor organs and ensures that organs provides Web search services to AOL subscrib-
are given to the most compatible recipient. It is ers by using both crawler-based and human-
another example of modern technology provid- powered directories of other search engines
ing a service that saves lives.
Since the Internet contains a wealth of infor- ♦ Ask (www.ask.com): human-powered search
mation, every health care provider should be that attempts to provide an exact page of
familiar with how to use the Internet as a research information in response to a question
tool. In order to do this, the health care provider ♦ Google (www.google.com): has the largest
must first become familiar with search engines. A collection of Web pages for a crawler-based
search engine, or search service, can be defined search engine, provides links to other sites,
as a database of Internet files. It usually consists provides Web page search results to other
of three parts: search engines
♦ Search program: commonly called a spider, ♦ Look Smart (www.looksmart.com): human-
wanderer, crawler, robot, or worm, the search powered directory of Web sites, provides
program explores different sites and identifies search results to many other search engines
and reads pages ♦ Lycos (www.lycos.com): began as crawler-
♦ Index: the search program creates a main based but switched to human-powered direc-
database that contains copies of all the infor- tory, obtains search results from other search
mation obtained engines
♦ Retrieval program: a program that searches ♦ MSN (http://search.msn.com): Microsoft’s
the database for specific information, lists all search service that uses results from many
sources of the information, and in most cases, other search engines
ranks the sources with the most relevant first ♦ Yahoo (www.yahoo.com): most popular search
service, largest human-powered directory on
There are three main types of search engines:
the Web with over 1 million sites listed, also
♦ Crawler based: creates an index by exploring uses results from other search engines
different sites on the Web and indexing the
sites To find relevant material on the Internet, it is
important to develop a strategy to locate infor-
♦ Human powered: creates an index when a mation on a specific topic in an efficient and
description of the information and key words effective way. Searching for information on a
are entered into the index by an individual topic such as “Does smoking or drinking alcohol
♦ Mixed: combines results of both crawler-based during pregnancy increase the chance of a pre-
and human-powered indexes mature birth?” can result in hundreds or even
328 CHAPTER 12
thousands of listings. Some of the listings may be ♦ Vary your search: To obtain as much informa-
relevant; others will not be. Various techniques tion as possible on a specific topic, it is wise to
can be used to limit the search and produce only use a variety of key word combinations. For
information that is specific to the topic. Basic example, to obtain information on the rela-
steps that should be followed include: tionship of smoking and alcohol during preg-
nancy on premature births, one search could
♦ Identify key words: Always try to determine the be: ⫹smoking OR cigarettes ⫹alcohol OR alco-
main words that pertain to the information holism ⫹pregnancy ⫹premature births. This
you desire. In the example above, the key search would bring up all information that
words are smoking, alcohol, pregnancy, and contains all the terms. A second search such
premature birth. Other words that are alterna- as ⫹alcohol OR alcoholism ⫹pregnancy ⫹pre-
tive ways of expressing the key words might mature births or even ⫹alcohol OR alcoholism
include cigarettes, premature infants, and ⫹pregnancy would provide additional infor-
alcoholism. mation on just the effects of alcohol. Many
articles might discuss the effects of alcohol on
♦ Combine key words: If any of the above key pregnancy and not discuss smoking. Similarly,
words are entered as separate searches, a large other articles might discuss the effects of
amount of information generated would not smoking, but not alcohol. By changing key
be pertinent. More specific information can words, additional pertinent information can
be obtained by telling the search engine to be located.
limit the search. This can be accomplished in
several ways. One of the easiest methods, rec- ♦ Use different search engines: If one search
ognized by most major search engines, is to engine does not locate pertinent information,
use math symbols: try different search engines. No search engine
a. Plus (⫹) symbol: tells an engine that you has access to all the information on the Inter-
want all words entered; for example: ⫹preg- net.
nancy ⫹alcohol ⫹premature birth will pro-
duce only listings that contain all three ♦ Evaluate the source of all information: The
words Internet can provide a wealth of information
b. Minus (–) symbol: tells the search engine to health care providers, but individuals using
that you want to find information with one it must also evaluate the information. Not all
word but not another word; for example, data are accurate or current. It is important to
search ⫹engines –car –automobile will check the source of any information (universi-
eliminate information on car or automo- ties, government agencies, and national orga-
bile engines nizations are usually reliable sources), the
c. Quotation marks (“): placed around a author (the person should have the proper
phrase or group of words tell a search education and credentials), the date of publi-
engine to locate pages that contain the cation if provided (information should be
exact same phrase in the order specified; recent and up to date), and references, if they
for example, “hearing aids” will provide are listed. For example, a search for diabetes
information only on hearing aids, not the mellitus will provide many journal articles,
disease AIDS. newsletters, organizational reports, and simi-
lar data. If material is published by an
organization such as the American Diabetic
♦ Boolean operators/connectors are also used
Association, the information should be accu-
to tell a search engine how to limit a search.
rate. If material is published by an individual
Common connectors include AND (used like
who states he has diabetes but can eat any
the plus sign), NOT used like the minus sign,
and all sweets, it would be wise to discount
OR used to present an alternative word such
this information.
as cigarettes OR smoking, and NEAR to indi-
cate words that should be used close to one Health care providers can research many top-
another. Most search engines that recognize ics on the Internet. They can obtain current health
Boolean operators require that the word be care information; learn about new diagnostic
keyed in capital letters. tests; research diseases, medications, therapies,
and other health concerns; and communicate computer plugs into the UPS, which has a surge
with other health care providers. The Internet is protector and a battery backup. If an electrical
an excellent learning tool and another example failure occurs, the computer operates on the bat-
of how technology has enhanced health care. tery backup in the UPS. Even when a UPS is in
Some reliable sources for medical information use, it is still important to backup data on the
on the Internet include: computer frequently. A computer “crash” can
cause a loss of all data and programs. Most health
♦ www.aap.org: the American Academy of Pedi-
care facilities perform daily backups onto disks
atrics
or tapes. To protect against loss by fire, natural
♦ www.ama-assn.org: the American Medical disasters, or theft, the backups should be stored
Association in a safe and secure location outside the health
♦ www.amhrt.org: heart and stroke guide from care facility. Many health care facilities have
the American Heart Association contracts with computer security companies to
♦ www.cancer.gov: the National Cancer Insti- have backups performed and stored in an off-site
tute facility.
Viruses are programs that contain instruc-
♦ www.cdc.gov: the Centers for Disease Control tions to alter the operation of the computer pro-
and Prevention grams, erase or scramble data on the computer,
♦ www.familydoctor.org: health information and/or allow access to information on the com-
from the American Academy of Family Physi- puter. Viruses can enter a computer by down-
cians loading information from the Internet, opening
♦ www.healthtouch.com: provides links to spe- e-mails, or using disks or tapes that contain
cific health organizations viruses. Antivirus software must be installed on
every computer to protect against these invasive
♦ www.healthypeople.gov/healthfinder: a health programs. The software should be updated on a
information site provided by the U.S. govern- daily basis. When the software issues a virus alert,
ment the computer user should follow the recommen-
♦ www.medicinenet.com: medical information dations of the software.
site that includes an “ask the experts” feature Firewalls are protective programs that limit
♦ www.medscape.com: a news service that has the ability of other computers to access a com-
full-text medical articles puter. A firewall alert will usually inform the user
that an outside program is trying to access the
♦ www.nih.gov: the National Institutes of computer. A strong firewall will prevent some
Health programs and hackers from entering the data-
♦ www.webmd.com: provides health and medi- base, but no firewall is foolproof. The best way to
cal news provided by physicians prevent access to the database is to use only a
dedicated computer to communicate with an
12:5 INFORMATION outside network or the Internet. Computers that
contain the databases should be networked only
Computer Protection and within the health care facility. When information
must be transferred to an outside source, the
Security information can be copied, placed on the dedi-
The widespread use of computerized records in cated computer, and then sent to the correct
health care has created the need for protecting recipient.
and securing the information. Electrical surges, Security to protect confidential patient infor-
power outages, viruses, and hackers (individuals mation is essential for any health care facility.
who use the Internet or networks to obtain unau- Guidelines to protect patient privacy have been
thorized access to the computer) can all result in established by many health care organizations
a loss of information and/or damage to the soft- including the American Medical Association and
ware and hardware of the computer. the American Health Information Management
To protect the computer from electrical Association. In addition, specific standards have
surges and power outages, an Uninterrupted been established through the Privacy Rule of the
Power Supply (UPS) device should be used. The Health Insurance Portability and Accountability
330 CHAPTER 12

A computer that reads and interprets X-rays?
A major tool used to diagnose tumors and cancer is imaging. Physicians use X-ray, ultra-
sound, magnetic resonance imaging (MRI), computerized tomography (CT), and mam-
mography to find cancer in its early stages. However, every type of image must be read by a
radiologist, a physician specializing in the study of radiographic images and radiation. Radi-
ologists are human. At times, they miss the early signs of a cancerous tumor on the image.
For example, studies have shown that radiologists reading mammograms (diagnostic images
used to detect breast cancer) miss more than 25 percent, or one of every four, early tumors.
Now, computer-aided detection (CAD) systems have been developed to help the radi-
ologist pinpoint suspicious areas. These systems use computing equipment and a special
image scanner to change images into numeric patterns that can be understood by the com-
puter. The CAD system then uses these patterns to locate suspicious areas and pinpoint
them for the radiologist. In short, the computer becomes a second pair of “eyes.”
Currently, the U. S. Food and Drug Administration (FDA) is evaluating a MammoReader
developed to aid radiologists in interpreting mammograms. Other CAD systems are being
developed for other types of diagnostic images. The systems may produce some “false” pos-
itives, or areas that appear suspicious but are in fact harmless. This may lead to the need for
additional tests and increased health care expense. However, if the CAD system locates the
25 percent of tumors that are missed by the human eye, it will save thousands of lives.
Act (HIPAA). (HIPAA is discussed in detail in ♦ Incorporate periodic password expirations

Chapter 5:1.) The main requirements established
by HIPAA to protect the confidentiality of health ♦ Secure workstations, record storage areas, and
care information include: computer hardware
♦ Develop and implement a security plan to ♦ Use encryption technology when health care
ensure compliance with HIPAA policies and information is transmitted electronically
procedures ♦ Create a system for destruction of duplicate or
♦ Prepare documents that patients sign to stipu- obsolete records (electronic and hard copy)
late consent for the use and dissemination of
health information Health care workers must make every effort
to protect and secure computerized records.
♦ Establish a certification process and educa- Passwords should be kept confidential and never
tional program to ascertain that all employees given to any other individual. When a password
understand the security plan is keyed into a computer, no other individual
♦ Require individuals to sign a contract verify- should be able to see the keyboard. Other indi-
ing that they will follow the security and pri- viduals should not be able to read the computer
vacy regulations screen when confidential patient information is
♦ Determine the level of security necessary for on the screen. Monitor screens that contain con-
each job classification fidential data should be cleared before leaving
the work area. E-mails or files from unknown par-
♦ Establish access levels that provide authoriza- ties must never be opened or downloaded onto
tion to confidential information on a need-to- the computer. If a virus or firewall alert occurs,
know basis instructions provided by the program should be
♦ Create a system that identifies date, time, and followed. Discarded hard copies or printouts
name of the individual who enters informa- should be shredded. If every worker in a health
tion into any database care facility follows the established security and
privacy policy, the confidentiality of patient infor- The widespread use of computers in health
mation will be protected. care makes it essential to protect and secure the
data to maintain patient confidentiality. Unin-
STUDENT: Go to the workbook and complete terrupted Power Supply devices, antivirus pro-
the assignment sheet for Chapter 12, Computer grams, firewalls, and strict control of access to
Technology in Health Care. computers can help protect both the computer
and the information it contains.
CHAPTER 12 SUMMARY INTERNET SEARCHES

The use of computers in health care has almost Use the suggested search engines in the Using
become a necessity. All health care workers the Internet section in this chapter to search the
should have basic computer literacy, meaning Internet for additional information on the follow-
an understanding of how the computer works ing topics:
and an understanding of the applications used
1. Computer hardware: obtain information about
in their particular health careers.
different computer systems and compare and
A computer system is a complete informa-
contrast the systems by searching the sites of
tion-processing center. All computer systems
computer manufacturers such as Gateway,
contain essentially the same parts: hardware
Dell, Compaq, and IBM
and software. The hardware consists of the ma-
chine components. The software consists of the 2. Computer software: search for different types of
programs, or instructions, that run the hardware software for health care providers
and allow the computer to perform specific tasks. 3. Diagnostic devices: search for additional
Each computer system also requires input, or information on blood analyzers, echocardio-
the information entered into the computer, and graphs, computerized tomography, magnetic
a central processing unit (CPU), which performs resonance imaging, positron emission tomog-
the operations of the computer by following the raphy, and ultrasonography
directions in the software. This results in output
(the processed information, or final product), 4. Organizations: search for additional informa-
which can be displayed on a screen, printed, tion and Internet links to the National Library
stored, or transmitted to another user. of Medicine, National Institutes of Health,
Computers are used in many aspects of Medical Literature Analysis and Retrieval
health care. They serve as information centers System (MEDLARS), and the Statistical Package
to provide patient information, schedule perfor Social Sciences (SPSS)
sonnel, and maintain records and inventory. 5. Search engines: search for information on the
Computers are also used as diagnostic tools by main search engines, advantages and disad-
performing blood tests or viewing body parts. vantages of the engines, and ways to use the
They are major educational tools, and many engines most effectively
computer-assisted instructional programs exist
to teach both health care workers and patients. 6. Computer security: search for information on
Computers are critical components in health antivirus and firewall programs, the effective-
care research. They are also a major way of com- ness of these programs, ways to protect a
municating for health care professionals and computer from hackers, and encryption coding
patients. The use of computers in health care
has proved they are efficient tools that enhance
the quality of patient care. REVIEW QUESTIONS
The Internet is used by almost every health
care worker. By using search engines and spe- 1. Define computer literacy.
cific techniques to obtain correct information, a
2. Differentiate between hardware and software.
health care worker can find a wealth of informa-
tion. It is important to ensure that any informa- 3. List five (5) examples of input devices and two
tion obtained is from reliable sources. (2) examples of output devices.
332 CHAPTER 12
4. Identify ways confidentiality of patient infor- tion: “Does hypertension affect some cultures
mation can be maintained while using com- and/or races more readily than others?”
puters. a. Identify the key words in the question.
b. List at least three (3) possible search phrases
5. Why is a contingency backup plan essential
using math symbols and/or Boolean
when computers are used to record informa-
connectors.
tion?
c. Which search engine will you use? Why?
6. Briefly describe the main uses of the following
8. Differentiate between an antivirus program
imaging techniques:
and a firewall program.
a. computerized tomography (CT)
b. magnetic resonance imaging (MRI) 9. List five (5) ways a health care worker can help
c. positron emission tomography (PET) meet HIPAA standards for maintaining confi-
d. ultrasonography dentiality of health care information while
using computer technology.
7. You are conducting an Internet search for
information on the following research ques-
CHAPTER 13 Promotion
of Safety
Chapter Objectives
Observe Standard ◆ Define body mechanics
Precautions
◆ Use correct body mechanics while performing
procedures in the laboratory or clinical area
Instructor’s Check—Call ◆ Observe all safety standards established by
Instructor at This Point OSHA, especially the Occupational Exposure
to Hazardous Chemicals Standard and the
Bloodborne Pathogen Standard
◆ Follow safety regulations stated while
Caution
performing in the laboratory area
◆ Observe all regulations for patient safety while
OBRA Requirement—Based performing procedures on a student partner in
on Federal Law the laboratory or clinical area, or on a patient
in any area
◆ List the four main classes of fire extinguishers
Math Skill
◆ Relate each class of fire extinguisher to the
specific fire(s) for which it is used
Legal Responsibility ◆ Simulate the operation of a fire extinguisher by
following the directions on the extinguisher
and specific measures for observing fire safety
Science Skill
◆ Locate and describe the operation of the
nearest fire alarm
Career Information ◆ Describe in detail the evacuation plan for the
laboratory area according to established
school policy
Technology
334 CHAPTER 13
KEY TERMS
base of support Material Safety Data Sheet Occupational Safety and
Bloodborne Pathogen (MSDS) Health Administration
Standard Occupational Exposure to (OSHA)
body mechanics Hazardous Chemicals safety standards
ergonomics Standard
fire extinguishers
13:1 INFORMATION
Using Body Mechanics
To prevent injury to yourself and others while
working in the health field, it is important that
you observe good body mechanics.
Body mechanics refers to the way in which
the body moves and maintains balance while
making the most efficient use of all its parts. Basic
rules for body mechanics are provided as guide-
lines to prevent strain and help maintain muscle
strength.
There are four main reasons for using good
body mechanics:
♦ Muscles work best when used correctly.
♦ Correct use of muscles makes lifting, pulling,
and pushing easier.
vents unnecessary fatigue and strain, and
saves energy.
vents injury to self and others.
Eight basic rules of good body mechanics FIGURE 13-1 Maintain a broad base of support
include: by keeping the feet 8–10 inches apart.
♦ Maintain a broad base of support by keep-
ing the feet 8–10 inches apart, placing one foot
slightly forward, balancing weight on both ♦ Use the weight of your body to help push or
feet, and pointing the toes in the direction of pull an object. Whenever possible, push, slide,
movement (figure 13-1). or pull rather than lift.
♦ Bend from the hips and knees to get close to ♦ Carry heavy objects close to the body. Also,
an object, and keep your back straight (figure stand close to any object or person being
13-2). Do not bend at the waist. moved.
♦ Use the strongest muscles to do the job. The ♦ Avoid twisting your body as you work. Turn
larger and stronger muscles are located in the with your feet and entire body when you
shoulders, upper arms, hips, and thighs. Back change direction of movement.
muscles are weak. ♦ Avoid bending for long periods.
Promotion of Safety 335
FIGURE 13-3 Some health care facilities now

require workers to wear back supports while lifting
or moving patients.
FIGURE 13-2 Bend from the hips and knees to

get close to an object.
♦ If a patient or object is too heavy for you to lift ports may also cause sweating, skin irritation,
alone, always get help. Mechanical lifts, trans- and increased abdominal pressure. They do
fer (gait) belts, wheelchairs, and other similar remind the wearer to use good body mechanics.
types of equipment are also available to help If a back support is used, it should be the correct
lift and move patients. size to provide the maximum benefit. When the
worker is performing strenuous tasks, the sup-
Some health care facilities now require health port should fit snugly. At other times, it should be
care workers to wear back supports while lifting loosened to decrease abdominal pressure.
or moving patients (figure 13-3). The supports are
supposed to help prevent back injuries, but their STUDENT: Go to the workbook and complete
use is controversial. Back supports may provide a the assignment sheet for 13:1, Using Body Mechan-
false sense of security as an individual tries to lift ics. Then return and continue with the procedure.
heavier loads. It is important to remember that a
back brace does not increase strength. Back sup-
PROCEDURE 13:1
Using Body Mechanics Procedure
Equipment and Supplies 2. Compare using a narrow base of sup-
Heavy book, bedside stand, bed with wheel port to using a broad base of support.
locks Stand on your toes, with your feet close
336 CHAPTER 13
PROCEDURE 13:1
together. Next, stand on your toes with port. Get close to the bed. Use the weight
your feet farther apart. Then, stand with of your body to push the bed forward.
your feet flat on the floor but close
6. Place the book on the bed. Pick up the
together. Finally, stand with your feet
book and place it on the bedside stand.
flat on the floor but approximately 8–10
Avoid twisting your body. Turn with your
inches apart and with one foot slightly
feet to place the book on the stand.
forward. Balance your weight on both
feet. You should feel the best support in NOTE: Remember that holding the book
the final position because the broad close to your body allows you to use the
base supports your body weight. strongest muscles.
3. Place the book on the floor. Bend from 7. Practice the rules of body mechanics by
the hips and knees (not the waist) and setting up situations similar to those
keep your back straight to pick up the listed in the previous steps. Continue
book. Return to the standing position. until the movements feel natural to
you.
4. Place the book between your thumb and
fingers, but not touching the palm of 8. Replace all equipment used.
your hand, and hold your hand straight
out in front of your body. Slowly move
your hand toward your body, stopping
several times to feel the weight of the
book in different positions. Finally, hold Practice
the book with your entire hand and Use the evaluation sheet for 13:1,
bring your hand close to your body. The Using Body Mechanics, to practice
final position should be the most com- this procedure. When you believe
fortable. you have mastered this skill, sign
the sheet and give it to your
NOTE: This illustrates the need to carry
instructor for further action.
heavy objects close to your body and to
use the strongest muscles to do the job.
5. Stand at either end of the bed. Release Final Checkpoint Using the criteria
the wheel locks on the bed. Position listed on the evaluation sheet, your
your feet to provide a broad base of sup- instructor will grade your performance.
♦ The Bloodborne Pathogen Standard

13:2 INFORMATION
Preventing Accidents and
Injuries CHEMICAL HAZARDS
The Occupational Safety and Health Admin- The Occupational Exposure to Hazardous
istration (OSHA), a division of the Department Chemicals Standard requires that employers
of Labor, establishes and enforces safety stan- inform employees of all chemicals and hazards in
dards for the workplace. Two main standards the workplace. In addition, all manufacturers
affect health care workers: must provide Material Safety Data Sheets
(MSDSs) with any hazardous products they sell
♦ The Occupational Exposure to Hazardous (figure 13-4). The MSDSs must provide the fol-
Chemicals Standard lowing information:
The Clorox Company

1221 Broadway Material Safety
Oakland, CA 94612
Tel. (510) 271-7000 Data Sheet
I Product: CLOROX REGULAR-BLEACH
Description: CLEAR, LIGHT YELLOW LIQUID WITH A CHARACTERISTIC CHLORINE ODOR
Other Designations Distributor Emergency Telephone Nos.

For Medical Emergencies call:
Clorox Sales Company
Clorox Bleach (800) 446-1014
1221 Broadway
EPA Reg. No. 5813-50 For Transportation Emergencies Chemtrec
Oakland, CA 94612
(800) 424-9300
II Health Hazard Data III Hazardous Ingredients
DANGER: CORROSIVE. May cause severe irritation or damage to eyes and Ingredient Concentration Exposure Limit
skin. Vapor or mist may irritate. Harmful if swallowed. Keep out of reach of Sodium hypochlorite 6.15% Not established
children. CAS# 7681-52-9
Some clinical reports suggest a low potential for sensitization upon exaggerated 3; 1
exposure to sodium hypochlorite if skin damage (e.g., irritation) occurs during Sodium hydroxide <1% 2 mg/m
exposure. Under normal consumer use conditions the likelihood of any adverse CAS# 1310-73-2 2 mg/m3; 2
health effects are low.
Medical conditions that may be aggravated by exposure to high concentrations
of vapor or mist: heart conditions or chronic respiratory problems such as
asthma, emphysema, chronic bronchitis or obstructive lung disease.
FIRST AID:
Eye Contact: Hold eye open and rinse with water for 15-20 minutes. Remove
contact lenses, after first 5 minutes. Continue rinsing eye. Call a physician. 1
Skin Contact: Wash skin with water for 15-20 minutes. If irritation develops, call ACGIH Threshold Limit Value (TLV) - Ceiling
a physician. 2
OHSA Permissible Exposure Limit (PEL) – Time Weighted Average (TWA)
Ingestion: Do not induce vomiting. Drink a glassful of water. If irritation
develops, call a physician. Do not give anything by mouth to an unconscious
person. None of the ingredients in this product are on the IARC, NTP or OSHA
Inhalation: Remove to fresh air. If breathing is affected, call a physician. carcinogen lists.
IV Special Protection and Precautions V Transportation and Regulatory Data

No special protection or precautions have been identified for using this product DOT/IMDG/IATA - Not restricted.
under directed consumer use conditions. The following recommendations are
given for production facilities and for other conditions and situations where there EPA - SARA TITLE III/CERCLA: Bottled product is not reportable under
is increased potential for accidental, large-scale or prolonged exposure. Sections 311/312 and contains no chemicals reportable under Section 313.
This product does contain chemicals (sodium hydroxide <0.2% and sodium
Hygienic Practices: Avoid contact with eyes, skin and clothing. Wash hands hypochlorite <7.35% ) that are regulated under Section 304/CERCLA.
after direct contact. Do not wear product-contaminated clothing for prolonged
TSCA/DSL STATUS: All components of this product are on the U.S.
periods.
TSCA Inventory and Canadian DSL.
Engineering Controls: Use general ventilation to minimize exposure to vapor or
mist.
Personal Protective Equipment: Wear safety glasses. Use rubber or nitrile
gloves if in contact liquid, especially for prolonged periods.
KEEP OUT OF REACH OF CHILDREN
VI Spill Procedures/Waste Disposal VII Reactivity Data

Spill Procedures: Control spill. Containerize liquid and use absorbents on Stable under normal use and storage conditions. Strong oxidizing agent.
residual liquid; dispose appropriately. Wash area and let dry. For spills of Reacts with other household chemicals such as toilet bowl cleaners, rust
multiple products, responders should evaluate the MSDS’s of the products for removers, vinegar, acids or ammonia containing products to produce hazardous
incompatibility with sodium hypochlorite. Breathing protection should be worn in gases, such as chlorine and other chlorinated species. Prolonged contact with
enclosed, and/or poorly ventilated areas until hazard assessment is complete. metal may cause pitting or discoloration.
Waste Disposal: Dispose of in accordance with all applicable federal, state, and
local regulations.
VIII Fire and Explosion Data IX Physical Data
Flash Point: None Boiling point........................................................................° F/100°C approx. 212
Special Firefighting Procedures: None Specific Gravity (H 2 0=1) .................................................................o F ~ 1.1 at 70
Solubility in Water ................................................................................. complete
Unusual Fire/Explosion Hazards: None. Not flammable or explosive. Product pH ............................................................................................................... ~11.4
does not ignite when exposed to open flame.
©
1963, 1991 THE CLOROX COMPANY
DATA SUPPLIED IS FOR USE ONLY IN CONNECTION WITH OCCUPATIONAL SAFETY AND HEALTH DATE PREPARED 05/05
FIGURE 13-4 Read the Material Safety Data Sheet (MSDS) before using any chemical product. (Courtesy
of the Clorox Company, Oakland, CA)
338 CHAPTER 13
♦ Product identification information about the

chemical ENVIRONMENTAL
♦ Protection or precautions that should be used SAFETY
while handling the chemical (for example,
wearing protective equipment or using only in Ergonomics is an applied science used to pro-
a well-ventilated area) mote the safety and well-being of a person by
adapting the environment and using techniques
♦ Instructions for the safe use of the chemical to prevent injuries. Ergonomics includes the cor-
♦ Procedures for handling spills, cleanup, and rect placement of furniture and equipment, train-
disposal of the product ing in required muscle movements, efforts to
♦ Emergency first-aid procedures to use if injury avoid repetitive motions, and an awareness of the
occurs environment to prevent injuries. The prevention
of accidents and injury centers around people
The Occupational Exposure to Hazardous and the immediate environment. The health
Chemicals Standard also mandates that all worker must be conscious of personal and
employers train employees on the proper proce- patient/resident safety at all times. In addition,
dures or policies to follow with regard to: every health care worker must be alert to unsafe
situations and report them immediately. Exam-
♦ Identifying the types and locations of all ples include burned-out lightbulbs, frayed elec-
chemicals or hazards trical cords, scalding water in a sink or bath area,
♦ Locating and using the MSDS manual con- missing floor tiles or torn carpet, and other simi-
taining all of the safety data sheets lar hazards.
♦ Reading and interpreting chemical labels and In addition, every health care worker must
hazard signs accept the responsibility for using good
judgment in all situations, asking questions when
♦ Using personal protective equipment (PPE) in doubt, and following approved policies and
such as masks, gowns, gloves, and goggles procedures to create a safe environment. Always
♦ Locating cleaning equipment and following remember that a health care worker has a legal
correct methods for managing spills and/or responsibility to protect the patient from harm
disposal of chemicals and injury.
♦ Reporting accidents or exposures and docu-
menting any incidents that occur
Equipment and Solutions
Safety
Basic rules that must be followed when working
BLOODBORNE with equipment and solutions include:
PATHOGEN STANDARD ♦ Do not operate or use any equipment until
you have been instructed on how to use it.
The Bloodborne Pathogen Standard has ♦ Read and follow the operating instructions for
mandates to protect health care providers from all major pieces of equipment. If you do not
diseases caused by exposure to body fluids. understand the instructions, ask for assis-
Examples of body fluids include blood and blood tance.
components, urine, stool, semen, vaginal secre-
tions, cerebrospinal fluid, saliva, mucus, and ♦ Do not operate any equipment if your instruc-
other similar fluids. Three diseases that can be tor/immediate supervisor is not in the room.
contracted by exposure to body fluids include ♦ Report any damaged or malfunctioning equip-
hepatitis B, caused by the hepatitis B virus, hepa- ment immediately. Make no attempt to use it.
titis C, caused by the hepatitis C virus, and Some facilities use a lockout tag system for
acquired immune deficiency syndrome (AIDS), damaged electrical or mechanical equipment.
caused by the human immunodeficiency virus. A locking device is placed on the equipment
The mandates of this standard are discussed in to prevent the equipment from being used
detail in Chapter 14:4. (figure 13-5).
FIGURE 13-6 Read the label on a solution bottle

at least three times to be sure you have the correct
solution.
diate supervisor or you can verify that they are

compatible.
FIGURE 13-5 Some facilities use a lockout tag ♦ Some solutions can be injurious or poisonous.
system for damaged equipment to prevent anyone
Avoid contact with your eyes and skin. Avoid
from using the equipment.
inhaling any fumes displaced by a solution.
Use only as directed.
♦ Do not use frayed or damaged electrical cords.
Do not use a plug if the third prong for ground- ♦ Store all chemical solutions in a locked cabi-
ing has been broken off. Never use excessive net or closet following the manufacturer’s rec-
force to insert a plug into an outlet. ommendations. For example, some solutions
must be kept at room temperature, while oth-
♦ Never handle any electrical equipment with
ers must be stored in a cool area.
wet hands or around water.
♦ Store all equipment in its proper place. Unused ♦ Dispose of chemical solutions according to
the instructions provided on the MSDS for the
equipment should not be left in a patient’s
solution.
room, a hallway, or a doorway.
♦ When handling any equipment, observe all ♦ If you break any equipment or spill any solu-
tions, immediately report the incident to your
safety precautions that have been taught.
instructor/immediate supervisor. You will be
♦ Read MSDSs before using any hazardous told how to dispose of the equipment or how
chemical solutions. to remove the spilled solution (figure 13-7).
♦ Never use solutions from bottles that are not
labeled.
♦ Read the labels of solution bottles at least
Patient/Resident Safety
three times during use to be sure you have the Basic rules that must be followed to protect a
correct solution (figure 13-6). patient or resident include:
♦ Do not mix any solutions together unless ♦ Do not perform any procedure on patients
instructed to do so by your instructor/imme- unless you have been instructed to do so.
340 CHAPTER 13
closed privacy curtains. Close the door and/or

draw curtains for privacy before beginning a
procedure on the patient (figure 13-8B).
♦ Always identify your patient. Be absolutely
positive that you have the correct patient.
Check the identification wristband, if present.
Ask the patient to state his or her name. Repeat
the patient’s name at least twice. Check the
name on the patient’s bed and on the patient’s
record.
♦ Always explain the procedure so the patient
knows what you are going to do (figure 13-8C).
Answer any questions and make sure you have
the patient’s consent before performing any
procedure. Never perform a procedure if a
patient refuses to allow you to do so.
♦ Observe the patient closely during any proce-
dure. If you notice any change, immediately
report this. Be alert to the patient’s condition
FIGURE 13-7 Follow proper procedure to clean at all times.
up spilled solutions. ♦ Frequently check the patient area, waiting
room, office rooms, bed areas, or home envi-
Make sure you have the proper authorization. ronment for safety hazards. Report all unsafe
Follow instructions carefully. Ask questions situations immediately to the proper person
if you do not understand. Use correct or or correct the safety hazard.
approved methods while performing any pro- ♦ Before leaving a patient/resident in a bed,
cedure. Avoid shortcuts or incorrect tech- observe all safety checkpoints. Make sure the
niques. patient is in a comfortable position. Check the
♦ Provide privacy for all patients. Knock on the bed to be sure that the side rails are elevated,
door before entering any room (figure 13-8A). if indicated; the bed is at the lowest level to the
Speak to the patient and identify yourself. Ask floor; and the wheels on the bed are locked to
for permission to enter before going behind prevent movement of the bed. Place the call
FIGURE 13-8A Always knock on FIGURE 13-8B Close the door FIGURE 13-8C Explain the
the door or speak before entering a and draw curtains for privacy before procedure and answer any ques-
patient’s room. beginning a procedure. tions to make sure you have the
patient’s consent.
signal (a bell can be used in a home situation) ♦ Wash your hands frequently. Hands should
(figure 13-9A) and other supplies such as the always be washed before and after any proce-
telephone, television remote control, fresh dure, and any time they become contami-
water, and tissues within easy reach of the nated during a procedure (figure 13-10).
patient/resident (figure 13-9B). Open the pri-
vacy curtains if they were closed. Leave the
♦ Keep your hands away from your face, eyes,
mouth, and hair.
area neat and clean, and make sure no safety
hazards are present. ♦ Dry your hands thoroughly before handling
any electrical equipment.
♦ Wear safety glasses when instructed to do so
Personal Safety and in situations that might result in possible
Basic rules that must be followed to protect your- eye injury.
self and others include: ♦ While working with your partner in patient
♦ Remember, it is your responsibility to protect simulations, observe all safety precautions
yourself and others from injury. taught in caring for a patient. Review the role
each of you will have before you begin practic-
♦ Use correct body mechanics while performing ing a procedure so each person knows his or
any procedure. her responsibilities. Avoid horseplay and prac-
♦ Wear the required uniform. tical jokes; they cause accidents.
♦ Walk—do not run—in the laboratory area or ♦ If any solutions come in contact with your
clinical area, in hallways, and especially on skin or eyes, immediately flush the area with
stairs. Keep to the right and watch carefully at cool water. Inform your instructor/immediate
intersections to avoid collisions. Use handrails supervisor.
on stairways. ♦ If a particle gets in your eye, inform your
♦ Promptly report any personal injury or acci- instructor/immediate supervisor. Do not try
dent, no matter how minor, to your instruc- to remove the particle or rub your eye.
tor/immediate supervisor.
♦ If you see an unsafe situation or a violation of STUDENT: Go to the workbook and complete
a safety practice, report it to your instructor/ the assignment sheet for 13:2, Preventing Acci-
immediate supervisor promptly. dents and Injuries. Then return and continue with
the procedure.
♦ Keep all areas clean and neat with all equip-
ment and supplies in their proper locations at
all times.
FIGURE 13-9A Lower the bed FIGURE 13-9B Make sure other FIGURE 13-10 Wash your
and place the call signal within easy supplies and equipment are conve- hands before and after any proce-
reach of the patient before leaving a niently placed within the patient’s dure, and any time they become
patient. reach. contaminated during a procedure.
342 CHAPTER 13
PROCEDURE 13:2
• Observe the patient during a proce-
Preventing Accidents dure. List points you should observe
and Injuries to note a change in the patient’s con-
dition.
Equipment and Supplies 7. Discuss the following situations with
another student and decide how you
Information section on Preventing Accidents
would handle them:
and Injuries, several bottles of solutions, lab-
oratory area with equipment • You see an unsafe situation or a viola-
tion of a safety practice
Procedure • You see a wet area on the laboratory
counter
• You get a small cut on your hand while
2. Review the safety standards in the infor- using a glass slide
mation section for Preventing Accidents
and Injuries. Note standards that are not • A solution splashes on your arm
clear and ask your instructor for an • A particle gets in your eye
explanation.
• A piece of equipment is not working
3. Examine several bottles of solutions. correctly
Read the labels carefully. Read the safety
or danger warnings on the bottles. Read • A bottle of solution does not have a
MSDSs provided with hazardous chem- label
icals. • You break a glass thermometer.
4. Practice reading the label three times to 8. Observe and practice all of the safety
be sure you have the correct solution. regulations as you work in the labora-
Read the label before taking the bottle tory.
off the shelf, before pouring from the
bottle, and after you have poured from 9. Study the regulations in preparation for
the bottle. the safety examination. You must pass
the safety examination.
5. Look at major pieces of equipment in
the laboratory. Read the operating 10. Replace all equipment used.
instructions for the equipment. Do not
operate the equipment until you are
taught how to do it correctly.
6. Role-play the following situations by Practice
using another student as a patient. Use the evaluation sheet for 13:2,
• Show ways to provide privacy for the Preventing Accidents and Injuries,
patient. to practice this procedure. When you
believe you have mastered this skill,
• Identify the patient. sign the sheet and give it to your
• Explain a procedure to the patient. instructor for further action.
• Check various patient areas in the
laboratory. Note any safety hazards
that may be present. Discuss how you Final Checkpoint Using the criteria
can correct the problems. Report your listed on the evaluation sheet, your
findings to your instructor. instructor will grade your performance.
♦ Class C: used on electrical fires such as fuse

13:3 INFORMATION boxes, appliances, wiring, and electrical out-
Observing Fire Safety lets; the C stands for nonconductive; if possi-
ble, the electricity should be turned off before
This information section provides you with basic using an extinguisher on an electrical fire
facts about fires, how they start, and how to pre-
vent them. This information is important for fire
♦ Class D: used on burning or combustible met-
als; often specific for the type of metal being
safety in the laboratory and work environment.
used and are not used on any other types of
Fires need three things in order to start (fig-
fires
ure 13-11):
♦ Oxygen: present in the air Many different types of fire extinguishers are
available. The main types include:
♦ Fuel: any material that will burn
♦ Heat: sparks, matches, flames ♦ Water: contains pressurized water and should
only be used on Class A fires
The major cause of fires is carelessness with ♦ Carbon dioxide: contains carbon dioxide gas
smoking and with matches. Other causes include that provides a smothering action on the fire
misuse of electricity (overloaded circuits, frayed by forming a cloud of cool ice or snow that
electrical wires, and/or improperly grounded displaces the air and oxygen; does leave a
plugs), defects in heating systems, spontaneous powdery, snowlike residue that irritates the
ignition, improper rubbish disposal, and arson. skin and eyes and can be dangerous if inhaled;
most effective on Class B or C fires
FIRE EXTINGUISHERS ♦ Dry chemical: contains a chemical that acts to
smother a fire; type BC extinguishers contain
Fire extinguishers are classified and labeled potassium bicarbonate or sodium bicarbon-
according to the kind of fire they extinguish. The ate, which leaves a mildly corrosive residue
main classes are: that must be cleaned up as soon as possible;
type ABC extinguishers contain monoammo-
♦ Class A: used on fires involving combustibles
nium phosphate, a yellow powder that leaves
such as paper, cloth, plastic, and wood
a sticky residue that can damage electrical
♦ Class B: used on flammable or combustible appliances such as computers; both residues
liquids such as gasoline, oil, paint, grease, and can irritate the skin and eyes; used on Class A,
cooking fat fires B, or C fires
♦ Halon: contains a gas that interferes with the
chemical reaction that occurs when fuels
burn; used on electrical equipment because it
does not leave a residue and will not damage
Heat appliances such as computers; most effective
on Class C fires
Most fire extinguishers are labeled with a dia-
gram and/or a letter showing the type of fire for
which they are effective (figure 13-12). Many
extinguishers are used on different types of fires
and will be labeled with more than one diagram
and/or letter. In addition, some extinguishers put
all of the diagrams on the label; however, a diago-
nal red line is drawn through any diagram that
depicts a fire for which the extinguisher should
not be used. For example, if a diagonal red line is
Fuel Fire Oxygen drawn through the diagram for electrical fires, it
FIGURE 13-11 The fire triangle shows the three means the extinguisher should not be used on
things needed to start a fire. any electrical fire. Health care workers must
344 CHAPTER 13
CLASSES OF FIRE EXTINGUISHERS
CLASS A
A
Ordinary
Used for fires of ordinary combustibles
Combustibles such as wood, paper, cloth, and plastics
CLASS B
B
Flammable
Used for fires of flammable liquids
Liquids and gases such as paint, gasoline,
oil, grease, and cooking fats
CLASS C
C
Electrical
Used for electrical fires such as fuse boxes,
Equipment wiring, electrical outlets, and appliances;
if possible, turn off the electricity before
using an extinguisher on this type of fire
CLASS D
D Used on burning or combustible metals
Combustible
Metals
such as magnesium, titanium, and sodium;
specific for the type of metal; not used on
other types of fires
FIGURE 13-12 Fire extinguishers contain diagrams and/or letters to show the type of fire on which they
should be used.
become familiar with the types and locations of

fire extinguishers in their place of employment
before a fire occurs so they are prepared to act
FIRE EMERGENCY PLAN
when faced with this type of situation. While working in a health care facility, know and
In case of fire, the main rule is to remain calm. follow the fire emergency plan established by the
If your personal safety is endangered, evacuate facility (figure 13-13). The plan usually states that
the area according to the stated method and all patients and personnel in immediate danger
sound the alarm. If the fire is small, confined to should be moved from the area. The alarm should
one area, and your safety is not endangered, be activated as quickly as possible. All doors and
determine what type of fire it is and use the proper windows should be closed, if possible, to prevent
extinguisher. drafts, which cause fire to spread more rapidly.
uations that can lead to fires. Some rules for pre-

venting fires are:
♦ Obey all “No Smoking” signs. Most health care
facilities are now “smoke-free” environments
and do not permit smoking anywhere on the
premises.
♦ Extinguish matches, cigarettes, and any other
flammable items completely. Do not empty
ashtrays into trash cans or plastic bags that
can burn. Always empty ashtrays into sepa-
rate metal cans or containers partially filled
with sand or water.
♦ Dispose of all waste materials in proper con-
tainers.
♦ Before using electrical equipment, check for
damaged cords or improper grounding. Avoid
FIGURE 13-13 All personnel must be familiar overloading electrical outlets.
with the fire emergency plan established by the
facility in which they work.
♦ Store flammable materials such as kerosene
or gasoline in proper containers and in a safe
area. If you spill a flammable liquid, wipe it up
immediately.
Electrical equipment and oxygen should be shut
off. Elevators should never be used during a fire. ♦ Do not allow clutter to accumulate in rooms,
The acronym RACE is frequently used to remem- closets, doorways, or traffic areas. Make sure
ber the important steps. RACE stands for: no equipment or supplies block any fire exits.
♦ R Rescue anyone in immediate danger. ♦ When oxygen is in use, observe special pre-
Move patients to a safe area. If the patient can cautions. Post a “No Smoking—Oxygen in Use”
walk, escort him or her to a safe area. At times sign. Remove all smoking materials, candles,
it may be necessary to move a patient in a bed lighters, and matches from the room. Avoid
or use the bed sheets as lift sheets to carry a the use of electrically operated equipment
patient to a safe area. whenever possible. Do not use flammable liq-
uids such as alcohol, nail polish, and oils.
♦ A Activate the alarm. Sound the alarm and Avoid static electricity by using cotton blan-
give the location and type of fire.
kets, sheets, and gowns.
♦ C Contain the fire. Close windows and doors
to prevent drafts. Shut off electrical equip-
ment and oxygen if your safety is not endan- DISASTER PLANS
gered.
In addition to fires, other types of disasters
♦ E Extinguish the fire or evacuate the area. If may occur. Examples include tornadoes,
the fire is small and contained, and you are
hurricanes, earthquakes, floods, and bomb
not in danger, locate the correct fire extin-
threats. In any type of disaster, stay calm, follow
guisher to extinguish the fire. If the fire is large
the policy of the health care facility, and provide
or spreading rapidly, or you or a patient/resi-
for the safety of yourself and the patient. It is
dent is in danger, evacuate the area.
important to note that health care workers are
By following the fire emergency plan, know- legally responsible for familiarizing themselves
ing the location of fire extinguishers and exit with disaster policies so appropriate action can
doors, and remaining calm, the health care be taken when a disaster strikes.
worker can help prevent loss of life or serious
injury during a fire. STUDENT: Go to the workbook and complete
Preventing fires is everyone’s job. Constantly the assignment sheet for 13:3, Observing Fire Safety.
be alert to causes of fires, and correct all sit- Then return and continue with the procedure.
346 CHAPTER 13
PROCEDURE 13:3
Observing Fire Safety
Equipment and Supplies
Fire alarm box, fire extinguishers
Procedure
1. Read the information section on Observ-
ing Fire Safety.
2. Learn the four classes of fire extinguish-
ers and know for which kind of fire each
type is used.
3. Locate the nearest fire alarm box. Read
the instructions on how to operate the
alarm. Be sure you could set off the
alarm in case of a fire.
4. Locate any fire extinguishers in the lab-
oratory area. Look for extinguishers in FIGURE 13-14A Check the extinguisher type
both the room and surrounding build- to make sure it is the correct one to use.
ing. Identify each extinguisher and the
kind of fire for which it is meant to be
used.
5. Learn how to operate a fire extinguisher.
Read the manufacturer’s operating
instructions carefully. Work with a prac-
tice extinguisher or do a mock demon-
stration.
CAUTION: Do not discharge a real extin-
guisher in the laboratory.
a. Check the extinguisher type to be
sure it is the proper one to use for the
mock fire (figure 13-14A).
b. Locate the lock or pin at the top han-
dle. Release the lock following the
manufacturer’s instructions (figure
13-14B).
FIGURE 13-14B Release the pin.
NOTE: During a mock demonstra-
tion, only pretend to release the lock. e. Aim the nozzle at the fire (figure
c. Grasp the handle to hold the extin- 13-14C).
guisher firmly in an upright position. f. Discharge the extinguisher. Use a side-
d. Stand approximately 6–10 feet from to-side motion. Spray toward the near
the near edge of the fire. edge of the fire at the bottom of the fire.
PROCEDURE 13:3
i. After an extinguisher has been used,
it must be recharged or replaced.
Another usable extinguisher must be
put in position when the extinguisher
is removed.
6. Check the policy in your area for evacu-
ating the laboratory area during a fire.
Practice the method and know the loca-
tions of all exits.
NOTE: Remember to remain calm and
avoid panic.
7. Replace all equipment used.
FIGURE 13-14C Aim the nozzle at the near

Practice
Use the evaluation sheet for 13:3,
edge of the fire, and push the handle to dis-
Observing Fire Safety, to practice
charge the extinguisher.
this procedure. When you believe
CAUTION: Do not spray into the center you have mastered this skill, sign
or top of the fire, because this will cause the sheet and give it to your
the fire to spread in an outward direc- instructor for further action.
tion.
g. Continue with the same side-to-side
motion until the fire is extinguished.
NOTE: The word PASS can help you
remember the correct steps:
Practice
Study the safety regulations
P Pull the pin. throughout Chapter 13 in
preparation for the safety
A Aim the extinguisher at the near
examination.
edge and bottom of the fire.
S Squeeze the handle to discharge the
extinguisher. Final Checkpoint Using the criteria
S Sweep the extinguisher from side to listed on the evaluation sheet, your
side at the base of the fire. instructor will grade your performance.
h. At all times, stay a safe distance from

Final Checkpoint Take the safety
the fire to avoid personal injury.
examination and obtain a passing grade
CAUTION: Avoid contact with resi- to demonstrate your knowledge of
dues from chemical extinguishers. safety.
348 CHAPTER 13

Draino for blood vessels?
Cardiovascular (heart and blood vessel) disease is the leading cause of death in the
United States. Fatty plaques, caused mainly by an accumulation of LDL (low-density lipo-
protein, or “bad” cholesterol), block the flow of blood in arterial walls, triggering a heart
attack or stroke. HDL (high-density lipoprotein, or “good” cholesterol) helps protect the
body from cardiovascular disease. HDL carries fats to the liver for disposal, helps prevent
clots, and decreases inflammation in the blood vessels. For years, researchers have tried to
find ways to increase the level of HDL while decreasing the level of LDL in the blood.
Scientists may have found the key to solve this problem in a small village in Italy. They
discovered that residents of this village seemed to be immune to heart disease. Research
showed that these individuals have a mutant gene that produces a powerful version of HDL.
Scientists have produced a synthetic version of this HDL called apo A-1 Milano. When it was
injected into a small group of volunteer heart patients, plaque in blood vessels was reduced
by 4 percent and no new plaque buildup occurred. Scientists called it a miracle “blood ves-
sel Draino.” However, apo A-1 Milano is expensive to produce because it is a protein. It also
must be injected into the body by an intravenous infusion, making it even more costly and
inconvenient. Research is now directed toward gene therapy where the codes for the apo
A-1 Milano protein are transferred into the body so the body can produce its own powerful
version of HDL.
Scientists are also evaluating other methods to increase levels of HDL. They have discov-
ered an enzyme called cholesteryl ester transfer protein that appears to reduce HDL levels
and increase the levels of harmful LDL. Research is being conducted on new drugs that will
block this enzyme. Who knows which approach will be most successful, but scientists will
find the answer.
CHAPTER 13 SUMMARY An awareness of the causes and prevention

of fires is essential. Every health care worker
should be familiar with the types and use of fire
Safety is the responsibility of every health care extinguishers. In addition, every facility has a fire
worker. It is essential that established safety emergency plan. By following the fire emergency
standards be observed by everyone. This pro- plan, knowing the location of fire extinguishers
tects the worker, the employer, and the patient. and exit doors, and remaining calm, the health
One important aspect of safety is the correct care worker can help prevent loss of life or seri-
use of body mechanics. Body mechanics refer to ous injury during a fire and/or a disaster.
the way the body moves and maintains balance
while making the most efficient use of all of its
parts. Practicing basic principles of good body
mechanics prevents strain and maintains mus- INTERNET SEARCHES
cle strength. In addition, correct body mechan-
ics make lifting, pulling, and pushing easier.
of this textbook to search the Internet for addi-
Knowing and following basic safety stan-
dards is also important. In this unit, basic stan-
dards are listed in regard to the use of equip- 1. Federal regulations: obtain more information
ment and solutions, patient safety, and personal on federal safety regulations by searching sites
safety. It is important for everyone to learn and of the Occupational Safety and Health Admin-
follow the established standards at all times. istration (OSHA), Occupational Exposure to
Hazardous Chemicals Standard, Bloodborne

Pathogen Standard, and Material Safety Data
REVIEW QUESTIONS
Sheets (MSDSs)
1. Define body mechanics and list four (4)
2. Ergonomics: search for additional information reasons why it is important to use good body
on ergonomics and environmental safety mechanics.
3. Diseases: obtain information on the causative 2. You are using an electrical microhematocrit
agents and methods of transmission for centrifuge to spin blood. You see smoke
hepatitis B and C and acquired immune coming from the back of the machine. What
deficiency syndrome (AIDS) should you do?
4. Fire safety: search for information on fire 3. List four (4) safety precautions that must be
prevention and fire safety followed while using solutions.
5. Fire extinguishers: search for various manufac- 4. Identify three (3) things that must be done
turers of fire extinguishers and obtain informa- before performing any procedure on a patient.
tion on the types of extinguishers, their main
uses, precautions for handling, and safety 5. State five (5) checkpoints that must be
rules that must be observed while using observed before leaving a patient/resident in
extinguishers bed.
6. Disasters: obtain information on safety proce- 6. List five (5) rules that must be followed while
dures that must be followed for tornadoes, oxygen is in use.
floods, hurricanes, earthquakes, bomb threats, 7. What does the acronym RACE stand for?
or explosions
8. Create a chart showing the four (4) main types
of fire extinguishers and the type of fire for
which each is effective.
9. What does the acronyn PASS stand for?
CHAPTER 14 Infection Control
Chapter Objectives
Observe Standard ◆ Identify five classes of microorganisms by
Precautions describing the characteristics of each class
◆ List the 6 components of the chain of infection
◆ Differentiate between antisepsis, disinfection,
Instructor at This Point and sterilization
◆ Define bioterrorism and identify at least four
ways to prepare for a bioterrorism attack
Safety—Proceed with ◆ Wash hands following aseptic technique
Caution ◆ Observe standard precautions while working
in the laboratory or clinical area
◆ Wash, wrap, and autoclave instruments, linen,
on Federal Law and equipment
◆ Operate an autoclave with accuracy and safety
◆ Follow basic principles on chemical disinfection
Math Skill ◆ Clean instruments with an ultrasonic unit
◆ Open sterile packages with no contamination
◆ Don sterile gloves with no contamination
◆ Prepare a sterile dressing tray with no
contamination
Science Skill ◆ Change a sterile dressing with no
contamination
◆ Don and remove a transmission-based
Career Information isolation mask, gloves, and gown
◆ Relate specific basic tasks to the care of a
patient in a transmission-based isolation unit
Technology
Infection Control 351
KEY TERMS
acquired immune deficiency contaminated pathogens (path⬘-oh-jenz⬙)
syndrome (AIDS) disinfection personal protective
aerobic droplet precautions equipment (PPE)
airborne precautions endogenous portal of entry
anaerobic epidemic portal of exit
antisepsis (ant⬙-ih-sep⬘-sis) exogenous protective (reverse) isolation
asepsis (a-sep⬘-sis) fomites protozoa (pro-toe-zo⬘-ah)
autoclave fungi (fun⬘-guy) reservoir
bacteria helminths rickettsiae (rik-et⬘-z-ah)
bioterrorism hepatitis B standard precautions
causative agent hepatitis C sterile
cavitation microorganism (my-crow- sterile field
(kav⬙-ih-tay⬘-shun) or⬘-gan-izm) sterilization
chain of infection mode of transmission susceptible host
chemical disinfection nonpathogens transmission-based
clean nosocomial isolation precautions
communicable disease opportunistic ultrasonic
contact precautions pandemic viruses
14:1 INFORMATION For example, a bacterium called Escherichia coli

(E. coli) is part of the natural flora of the large
Understanding the Principles intestine. If E. coli enters the urinary system,
of Infection Control however, it causes an infection.
To grow and reproduce, microorganisms need
Understanding the basic principles of certain things. Most microorganisms prefer a
infection control is essential for any warm environment, and body temperature is ideal.
health care worker in any field of health care. The Darkness is also preferred by most microorgan-
principles described in this unit provide a basic isms, and many are killed quickly by sunlight. In
knowledge of how disease is transmitted and the addition, a source of food and moisture is needed.
main ways to prevent disease transmission. Some microorganisms, called aerobic organisms,
A microorganism, or microbe, is a small, require oxygen to live. Others, called anaerobic
living organism that is not visible to the naked organisms, live and reproduce in the absence of
eye. It must be viewed under a microscope. oxygen. The human body is the ideal supplier of all
Microorganisms are found everywhere in the the requirements of microorganisms.
environment, including on and in the human
body. Many microorganisms are part of the nor-
mal flora (plant life adapted for living in a specific
environment) of the body and are beneficial in CLASSES OF
maintaining certain body processes. These are
called nonpathogens. Other microorganisms
MICROORGANISMS
cause infection and disease and are called patho- There are many different classes of microorgan-
gens, or germs. At times, a microorganism that is isms. In each class, some of the microorganisms
beneficial in one body system can become patho- are pathogenic to humans. The main classes
genic when it is present in another body system. include:
352 CHAPTER 14
♦ Bacteria: These are simple, one-celled organ- Flagellated

forms
isms that multiply rapidly. They are classified
by shape and arrangement. Cocci are round or Bacilli
spores
spherical in shape (figure 14-1). If cocci occur
in pairs, they are diplococci. Diplococci bacte-
ria cause diseases such as gonorrhea, menin-
gitis, and pneumonia. If cocci occur in chains,
they are streptococci. A common streptococ-
cus causes a severe sore throat (strep throat)
and rheumatic fever. If cocci occur in clusters
or groups, they are staphylococci. These are
the most common pyogenic (pus-producing)
microorganisms. Staphylococci cause infec-
tions such as boils, urinary tract infections,
wound infections, and toxic shock. Rod-
shaped bacteria are called bacilli (figure 14-2).
They can occur singly, in pairs, or in chains.
Many bacilli contain flagella, which are thread-
like projections that are similar to tails and Bacilli
allow the organisms to move. Bacilli also have FIGURE 14-2 Bacilli bacteria.
the ability to form spores, or thick-walled cap-
sules, when conditions for growth are poor. In
Vibrios
the spore form, bacilli are extremely difficult
to kill. Diseases caused by different types of
bacilli include tuberculosis, tetanus, pertussis,
(whooping cough), botulism, diphtheria, and
typhoid. Bacteria that are spiral or corkscrew
in shape are called spirilla (figure 14-3). These
include the comma-shaped vibrio and the
corkscrew-shaped spirochete. Diseases caused
by spirilla include syphilis and cholera. Anti-
biotics are used to kill bacteria. However, some
strains of bacteria have become antibiotic-
Streptococci Staphylococci
Spirilla Spirochetes
FIGURE 14-3 Spirilla bacteria.
resistant, which means that the antibiotic is

no longer effective against the bacteria.
Methicillin-resistant staphylococcus is an
example. It causes a severe Staph infection
that is difficult to treat because it is resistant to
many different antibiotics.
♦ Protozoa: These are one-celled animal-like
Diplococci Micrococci organisms often found in decayed materials,
FIGURE 14-1 Kinds of cocci bacteria. animal or bird feces, insect bites, and con-
taminated water (figure 14-4). Many contain these insects. Rickettsiae cause diseases such
flagella, which allow them to move freely. as typhus fever and Rocky Mountain spotted
Some protozoa are pathogenic and cause dis- fever. Antibiotics are effective against many
eases such as malaria, amebic dysentery different rickettsiae.
(intestinal infection), trichomonas, and Afri- ♦ Viruses: These are the smallest micro-
can sleeping sickness. organisms, visible only using an electron
♦ Fungi: These are simple, plantlike organisms microscope (figure 14-6A and B). They cannot
that live on dead organic matter. Yeasts and reproduce unless they are inside another liv-
molds are two common forms that can be ing cell. They are spread from human to
pathogenic. They cause diseases such as ring- human by blood and other body secretions. It
worm, athlete’s foot, histoplasmosis, yeast is important to note that viruses are more dif-
vaginitis, and thrush (figure 14-5). Antibiotics ficult to kill because they are resistant to many
do not kill fungi. Antifungal medications are disinfectants and are not affected by antibiot-
available for many of the pathogenic fungi, ics. Viruses cause many diseases including the
but they are expensive, must be taken inter- common cold, measles, mumps, chicken pox,
nally for a long period, and may cause liver herpes, warts, influenza, and polio. New and
damage. different viruses emerge constantly because
♦ Rickettsiae: These are parasitic microorgan- viruses are prone to mutating and changing
isms, which means they cannot live outside genetic information. In addition, viruses that
the cells of another living organism. They are infect animals can mutate to infect humans,
commonly found in fleas, lice, ticks, and mites, often with lethal results. There are many
and are transmitted to humans by the bites of examples of these viruses. Severe acute respi-
FIGURE 14-4 An intestinal protozoan, FIGURE 14-6A Electron micrographs of the

Entamoeba coli. (Courtesy of the Centers for various types of herpes simplex virus. (Courtesy of
Disease Control and Prevention, Atlanta, GA) the Centers for Disease Control and Prevention,
Atlanta, GA)
FIGURE 14-5 The yeast (fungus) called thrush FIGURE 14-6B Electron micrograph of the hepati-
causes these characteristic white patches on the tis B virus. (Courtesy of the Centers for Disease
tongue. Control and Prevention, Atlanta, GA)
354 CHAPTER 14
ratory syndrome (SARS) is caused by a variant drome (AIDS). Hepatitis B, or serum hepatitis,
of the coronavirus family that causes the com- is caused by the HBV virus and is transmitted
mon cold. It is characterized by flu-like symp- by blood, serum, and other body secretions. It
toms that can lead to respiratory failure and affects the liver and can lead to the destruc-
death. West Nile virus (WNV) is a mosquito- tion and scarring of liver cells. A vaccine has
borne flavivirus that first infected birds but been developed to protect individuals from
now infects humans. In some individuals, it this disease. The vaccine is expensive and
causes only a mile febrile illness. In other indi- involves a series of three injections. Under
viduals who are older or have poor immune federal law, employers must provide the vac-
systems, it can cause severe neurologic ill- cination at no cost to any health care worker
nesses such as encephalitis or meningitis, with occupational exposure to blood or other
which can lead to death. Monkeypox, a hanta- body secretions that may carry the HBV virus.
virus that affects monkeys, other primates, An individual does have the right to refuse the
and rodents, mutated and spread to humans. vaccination, but a written record must be kept
Infection usually occurs after contacting body proving that the vaccine was offered. Hepati-
secretions or excretions (urine and stool) of tis C is caused by the hepatitis C virus, or HCV,
infected animals or ingesting food that has and is transmitted by blood and blood-con-
been contaminated by fluids from infected taining body fluids. Many individuals who
animals. A major outbreak occurred in the contract the disease are asymptomatic (dis-
American southwest when infected prairie play no symptoms); others have mild symp-
dogs contaminated food with fecal material. toms that are often diagnosed as influenza or
Monkeypox is similar to smallpox. It causes flu. In either case, HCV can cause serious liver
severe flu-like symptoms, lymphadenopathy damage. At present, there is no preventive
(disease of the lymph nodes), and pustules immunization, but a vaccine is being devel-
that cause severe scarring of the skin. If the oped. Both HBV and HCV are extremely diffi-
eyes are infected, blindness can occur. It can cult to destroy. These viruses can even remain
be prevented and/or treated with a smallpox active for several days in dried blood. Health
vaccination. Filoviruses such as Ebola and care workers must take every precaution to
Marburg first affected primates and then protect themselves from hepatitis viruses.
spread to humans. These viruses cause hem- Acquired immune deficiency syndrome
orrhagic fever, a disease that begins with fever, is caused by the human immunodeficiency
chills, headache, myalgia (muscle pain), and a virus (HIV) and suppresses the immune sys-
skin rash. It quickly progresses to jaundice, tem. An individual with AIDS cannot fight off
pancreatitis, liver failure, massive hemorrhag- many cancers and infections that would not
ing throughout the body, delirium, shock, and affect a healthy person. Presently, there is no
death. Most outbreaks of hemorrhagic fever cure and no vaccine is available, so it is impor-
have been in Africa, but isolated cases have tant for the health care worker to take precau-
appeared in other parts of the world when tions to prevent the spread of this disease.
individuals were in contact with infected pri-
mates. A new H5N1 virus that causes avian or ♦ Helminths: These are multicellular parasitic
bird flu has devastated bird flocks in many organisms commonly called worms or flukes.
countries. The infection has appeared in They are transmitted to humans when humans
humans, but most cases have resulted from ingest the eggs or larvae in contaminated food,
contact with infected poultry or contaminated ingest meat contaminated with the worms, or
surfaces. The spread from one person to get bitten by infected insects. Some worms
another has been reported only rarely. How- can also penetrate the skin to enter the body.
ever, because the death rate for bird flu is Examples of helminths include: hookworms,
between 50 and 60 percent, a major concern is which attach to the small intestine and can
that the H5N1 virus will mutate and spread infect the heart and lungs; ascariasis, which
more readily. In addition to these viruses, there live in the small intestine and can cause an
are three other viral diseases of major concern obstruction of the intestine; trichinella spira-
to the health care worker: hepatitis B, hepati- lis, which causes trichinosis and is contracted
tis C, and acquired immune deficiency syn- by eating raw or inadequately cooked pork
products; enterobiasis, which is commonly

called pinworm and affects mainly young chil- CHAIN OF INFECTION
dren; and taenia solium or pork tapeworm,
For disease to occur and spread from one indi-
which is contracted by eating inadequately
vidual to another, certain conditions must be
cooked pork.
met. These conditions are commonly called the
chain of infection (figure 14-7). The parts of
the chain include:
♦ Causative agent: a pathogen, such as a bac-
TYPES OF INFECTION terium or virus that can cause a disease
Pathogenic microorganisms cause infection and ♦ Reservoir: an area where the causative agent
disease in different ways. Some pathogens pro- can live; some common reservoirs include the
duce poisons, called toxins, which harm the body. human body, animals, the environment, and
An example is the bacillus that causes tetanus, fomites, or objects contaminated with infec-
which produces toxins that damage the central tious material that contains the pathogens.
nervous system. Some pathogens cause an aller- Common fomites include doorknobs, bed-
gic reaction in the body, resulting in a runny nose, pans, urinals, linens, instruments, and speci-
watery eyes, and sneezing. Other pathogens men containers.
attack and destroy the living cells they invade. An ♦ Portal of exit: a way for the causative agent
example is the protozoan that causes malaria. It to escape from the reservoir in which it has
invades red blood cells and causes them to rup- been growing. In the human body, pathogens
ture. can leave the body through urine, feces, saliva,
Infections and diseases are also classified as blood, tears, mucous discharge, sexual secre-
endogenous, exogenous, nosocomial, or oppor- tions, and draining wounds.
tunistic. Endogenous means the infection or
disease originates within the body. These include
♦ Mode of transmission: a way that the caus-
ative agent can be transmitted to another res-
metabolic disorders, congenital abnormalities,
ervoir or host where it can live. The pathogen
tumors, and infections caused by microorgan-
can be transmitted in different ways. One way
isms within the body. Exogenous means the
is by direct contact, which includes person-to-
infection or disease originates outside the body.
person contact (physical or sexual contact) or
Examples include pathogenic organisms that
contact with a body secretion containing the
invade the body, radiation, chemical agents,
pathogen. Contaminated hands are one of the
trauma, electric shock, and temperature extremes.
most common sources of direct contact trans-
A nosocomial infection is one acquired by an
mission. Another way is by indirect contact,
individual in a health care facility such as a hos-
when the pathogen is transmitted from con-
pital or long-term care facility. Nosocomial infec-
taminated substances such as food, air, soil,
tions are usually present in the facility and
insects, feces, clothing, instruments, and
transmitted by health care workers to the patient.
equipment. Examples include touching con-
Many of the pathogens transmitted in this man-
taminated equipment and spreading the
ner are antibiotic-resistant and can cause serious
pathogen on the hands, breathing in droplets
and even life-threatening infections in patients.
carrying airborne infections, and contacting
Common examples are staphylococcus, pseudo-
vectors (insects, rodents, or small animals),
monas, and enterococci. Infection-control pro-
such as being bitten by an insect carrying a
grams are used in health care facilities to prevent
pathogen.
and deal with nosocomial infections. Opportu-
nistic infections are those that occur when the ♦ Portal of entry: a way for the causative agent
body’s defenses are weak. These diseases do not to enter a new reservoir or host. Some ways
usually occur in individuals with intact immune pathogens can enter the body are through
systems. Examples include the development of breaks in the skin, breaks in the mucous mem-
Kaposi’s sarcoma (a rare type of cancer) or Pneu- brane, the respiratory tract, the digestive tract,
mocystis carinii pneumonia in individuals with the genitourinary tract, and the circulatory
AIDS. system. If the defense mechanisms of the body
356 CHAPTER 14
Early recognition of signs of infection

Rapid, accurate identification
of organisms
Medical asepsis
Treatment of Causative Standard precautions
underlying agent
diseases Employee health
Recognition
of high-risk Source Environmental
patients Susceptible or sanitation
host reservoir Disinfection/
Immunization sterilization
to prevent Involves
disease all health
care workers—
YOU
Wound care Portal Portal Medical asepsis

of of
entry exit Personal protective
equipment
Catheter
care Handwashing
Control of excretions
Medical Mode of & secretions
asepsis transmission Trash & waste
Standard disposal
precautions Standard Standard precautions
precautions
Handwashing Transmission-based precautions
Sterilization Food handling

Medical asepsis Air flow control
FIGURE 14-7 Note the components in the chain of infection and the ways in which the chain can be broken.
are intact and the immune system is function- ♦ Susceptible host: a person likely to get an
ing, a human can frequently fight off the caus- infection or disease, usually because body
ative agent and not contract the disease. Body defenses are weak
defenses include:
mucous membrane: lines the respiratory, Health care workers must constantly be aware
digestive, and reproductive tracts and traps of the parts in the chain of infection. If any part of
pathogens the chain is eliminated, the spread of disease or
cilia: tiny, hairlike structures that line the infection will be stopped. A health care worker
respiratory tract and propel pathogens out of who is aware of this can follow practices to inter-
the body rupt or break this chain and prevent the trans-
coughing and sneezing mission of disease. It is important to remember
hydrochloric acid: destroys pathogens in the that pathogens are everywhere and that prevent-
stomach ing their transmission is a continuous process.
tears in the eye: contain bacteriocidal (bacteria-
killing) chemicals
fever
ASEPTIC TECHNIQUES
inflammation: leukocytes, or white blood A major way to break the chain of infection is to
cells, destroy pathogens use aseptic techniques while providing health
immune response: body produces antibodies, care. Asepsis is defined as the absence of dis-
protective proteins that combat pathogens, ease-producing microorganisms, or pathogens.
and protective chemicals secreted by cells, Sterile means free from all organisms, both
such as interferon and complement pathogenic and nonpathogenic, including spores
and viruses. Contaminated means that organ- ganisms have been used in biologic warfare.
isms and pathogens are present. Any object or Some examples include:
area that may contain pathogens is considered to
♦ The Tartar army throwing bodies of dead
be contaminated. Aseptic techniques are directed
plague victims over the walls of a city called
toward maintaining cleanliness and eliminating
Caffa in 1346, causing an epidemic of plague
or preventing contamination. Common aseptic
in the city
techniques include handwashing, good personal
hygiene, use of disposable gloves when contact- ♦ The British army providing Delaware Indians
ing body secretions or contaminated objects, with blankets and handkerchiefs contami-
proper cleaning of instruments and equipment, nated with smallpox in 1763, resulting in a
and thorough cleaning of the environment. major outbreak of smallpox among the Indian
Various levels of aseptic control are possible. population
These include: ♦ The Germans using a variety of animal and
♦ Antisepsis: Antiseptics prevent or inhibit human pathogens in World War I
growth of pathogenic organisms but are not ♦ The Japanese military using prisoners of war
effective against spores and viruses. They can to experiment with many different pathogens
usually be used on the skin. Common examin World War II
ples include alcohol and betadine. ♦ The United States, Canada, the Soviet Union,
♦ Disinfection: This is a process that destroys and the United Kingdom developing biologic
or kills pathogenic organisms. It is not always weapons programs until the late 1960s
effective against spores and viruses. Chemical
♦ The release of sarin gas in Tokyo in 1995
disinfectants are used in this process. Disin-
fectants can irritate or damage the skin and ♦ The mail attack with anthrax by an unknown
are used mainly on objects, not people. Some individual or individuals in the United States
common disinfectants are bleach solutions in 2001
and zephirin. Today, there is a major concern that these bio-
♦ Sterilization: This is a process that destroys logic agents will be used not only in wars, but also
all microorganisms, both pathogenic and against unsuspecting civilians.
nonpathogenic, including spores and viruses.
Steam under pressure, gas, radiation, and
chemicals can be used to sterilize objects. An BIOLOGIC AGENTS
autoclave is the most common piece of equip-
ment used for sterilization. Many different microorganisms can cause dis-
eases in humans, animals, and plants. However,
In the sections that follow, correct methods of only a limited number are considered to be ideal
aseptic techniques are described. It is important for bioterrorism. Six characteristics of the “ideal”
for the health care worker to know and use these microorganism include:
methods in every aspect of providing health care
to prevent the spread and transmission of disease. ♦ Inexpensive and readily available or easy to
produce
STUDENT: Go to the workbook and complete ♦ Spread through the air by winds or ventilation
the assignment sheet for 14:1, Understanding the systems and inhaled into the lungs of poten-
Principles of Infection Control. tial victims, or spread by ingesting contami-
nated food or water
14:2 INFORMATION ♦ Survives sunlight, drying, and heat
Bioterrorism ♦ Causes death or severe disability
♦ Easily transmitted from person to person
INTRODUCTION ♦ Difficult to prevent and/or has no effective
treatment
Bioterrorism is the use of microorganisms, or
biologic agents, as weapons to infect humans, The Centers for Disease Control and Preven-
animals, or plants. Throughout history, microor- tion (CDC) has identified and classified major
358 CHAPTER 14
bioterrorism agents. High-priority agents that ♦ Plague: This is an infectious disease that is
have been identified include: caused by bacteria called Yersinia pestis. Usu-
♦ Smallpox: Smallpox is a highly contagious ally plague is transmitted by the bites of
infectious disease that is caused by a variola infected fleas. In some cases, the organism
virus. A smallpox vaccination can provide pro- enters the body through a break in the skin or
tection against some types of smallpox, but by contact with tissue of an infected animal.
one type, hemorrhagic smallpox, is usually Rats, rock squirrels, prairie dogs, and chip-
fatal. Until the 1970s, people were vaccinated munks are the most common sources for
against smallpox. However, after many years plague in the United States. If the disease is
with no reported cases, the vaccinations were not treated immediately with antibiotics, the
no longer required. Now, with the threat of a infection spreads to the blood and lungs, and
smallpox bioterrorism attack, the U.S. govern- causes death. No vaccine for plague is avail-
ment has started a new vaccination program. able in the United States.
The program encourages first responders, ♦ Botulism: Botulism is a paralytic illness caused
police, fire department, and health care per- by a nerve toxin produced by bacteria called
sonnel to be vaccinated. Clostridium botulinum. Three main types of
♦ Anthrax: Anthrax is an infectious disease botulism exist. One type is caused by eating
caused by the spores of bacteria called Bacil- foods that contain the toxin. A second type is
lus anthracis. The spores are highly resistant caused by the presence of the toxin in a wound
to destruction and can live in soil for years. or injury to the skin. A third type occurs in
Grazing animals such as cattle, sheep, and infants who eat the spores that then grow in
goats eat the contaminated soil and become the intestine and release the toxin. The toxin
infected. Humans develop anthrax by expo- rapidly causes muscle paralysis. If it is not
sure through the skin (cutaneous) (figure treated with an antitoxin, the paralysis spreads
14-8), by eating undercooked or raw infected to the respiratory muscles and causes death.
meat (gastrointestinal), or by inhaling the ♦ Tularemia: This is an infectious disease caused
spores (pulmonary). Cutaneous and gastroin- by bacteria called Francisella tularensis. This
testinal anthrax are usually treated success- bacteria is commonly found in animals such
fully with antibiotics, but some victims die. as rats, rabbits, and insects (ticks and deer-
Inhalation anthrax causes death in more than flies). Humans get the disease through the bite
80 percent of its victims. An anthrax vaccine is of an infected animal or insect, by eating con-
available for prevention. The military has an taminated food, by drinking contaminated
active vaccination program. water, or by breathing in the bacteria. The dis-
ease causes death if it is not treated with
appropriate antibiotics. Currently, the Food
and Drug Administration (FDA) is reviewing a
vaccine, but it is not available in the United
States.
♦ Filoviruses: A filovirus is an infectious disease
that causes severe hemorrhagic fever. Two
filoviruses have been identified. They are the
Ebola viruses and the Marburg virus. The
source of the viruses is still being researched,
but the common belief is that the viruses are
transmitted from animals such as bats. Once
the viruses affect a human, the disease is
spread rapidly from person to person by con-
tact with body fluids. No effective treatment
exists, and 50–90 percent of infected individu-
FIGURE 14-8 Cutaneous (skin) anthrax is usually
treated successfully with antibiotics. (Courtesy of als die.
the Centers for Disease Control Public Image Many other pathogenic microorganisms can
Library) be used in a bioterrorism attack. In fact, any
pathogenic organism could be used in a bioter- ♦ Improving communications so information

rorism attack. For this reason, health care work- on bioterrorism is transmitted quickly and
ers must be constantly alert to the threat of efficiently
infection with a biologic agent.
Every health care worker must constantly be alert
to the threat of bioterrorism. In today’s world, it is
PREPARING FOR likely that an attack will occur. Careful prepara-
tion and thorough training can limit the effect of
BIOTERRORISM the attack and save the lives of many people.
A bioterrorism attack could cause an epidemic STUDENT: Go to the workbook and complete
and public health emergency. Large numbers of the assignment sheet for 14:2, Bioterrorism.
infected people would place a major stress on
health care facilities. Fear and panic could lead to
riots, social disorder, and disregard for authority.
For these reasons, the Bioterrorism Act of 2002
14:3 INFORMATION
was passed by Congress and signed into law in Washing Hands
June 2002. This act requires the development of a
comprehensive plan against bioterrorism to Handwashing is a basic task required in
increase security in the United States. any health occupation. The method
Preparing for bioterrorism will involve gov- described in this unit has been developed to
ernment at all levels—local, regional, state, and ensure that a thorough cleansing occurs. An asep-
national. Some of the major aspects of prepara- tic technique is a method followed to prevent the
tion include: spread of germs or pathogens. Handwashing is
the most important method used to practice asep-
♦ Community-based surveillance to detect early tic technique. Handwashing is also the most effec-
indications of a bioterrorism attack tive way to prevent the spread of infection.
♦ Notification of the public when a high-risk The hands are a perfect medium for the
situation is detected spread of pathogens. Thoroughly washing the
♦ Strict infection-control measures and public hands helps prevent and control the spread of
education about the measures pathogens from one person to another. It also
helps protect the health worker from disease and
♦ Funding for studying pathogenic organisms, illness.
developing vaccines, researching treatments, The Centers for Disease Control and Preven-
and determining preventive actions tion (CDC) published the results of handwashing
♦ Strict guidelines and restrictions for purchas- research and new recommendations for hand
ing and transporting pathologic microorgan- hygiene in 2002. The recommendations call for
isms regular handwashing using plain soap and water,
♦ Mass immunization, especially for military, antiseptic handwashing using an antimicrobial
first responders, police, fire department, and soap and water, and antiseptic hand rubs (water-
health care personnel less handwashing) using alcohol-based hand
cleaners. Regular handwashing is recommended
♦ Increased protection of food and water sup- for routine cleansing of the hands when the hands
plies are visibly dirty or soiled with blood or other body
♦ Training personnel to properly diagnose and fluids. Antiseptic handwashing is recommended
treat infectious diseases before invasive procedures, in critical care units,
♦ Establishing emergency management policies while caring for patients on specific organism
transmission-based precautions, and in specific
♦ Criminal investigation of possible threats circumstances defined by the infection-control
♦ Improving the ability of health care facilities program of the health care facility. Antiseptic hand
to deal with an attack by increasing emer- rubs are recommended if the hands are not visibly
gency department space, preparing decon- dirty or are not soiled with blood or body fluids.
tamination areas, and establishing isolation Handwashing should be performed fre-
facilities quently. It should be done:
360 CHAPTER 14
♦ When you arrive at the facility and immedi- ♦ Dry paper towels must be used to turn the
ately before leaving the facility faucet on and off. This action prevents con-
♦ Before and after every patient contact tamination of the hands from pathogens on
the faucet. A dry towel must be used because
♦ After contact with a patient’s intact skin (for pathogens can travel more readily through a
example, after taking a blood pressure) wet towel.
♦ Before moving from a contaminated body site Nails also harbor dirt and pathogens, and must
to a clean body site during patient care (for
be cleaned during the handwashing process. An
example, before washing the patient’s hands
orange/cuticle stick can be used. Care must be
after removing a bedpan)
taken to use the blunt end of the stick because
♦ Any time the hands become contaminated the pointed end can injure the nailbeds. A brush
during a procedure can also be used to clean the nails. If a brush or
♦ Before applying and immediately after remov- orange stick is not available or the nails are not
ing gloves visibly dirty, the nails can be rubbed against the
palm of the opposite hand to get soap under the
♦ Any time gloves are torn or punctured
nails. Most health care facilities prohibit the use
♦ Before and after handling any specimen of artificial nails and require that nails be kept
♦ After contact with any soiled or contaminated short, usually less than 1/4-inch long. Artificial or
item long nails can harbor organisms and increase the
risk for infection for both the patient and health
♦ After picking up any item off the floor
care worker. In addition, long nails can puncture
♦ After personal use of the bathroom or tear gloves.
♦ After you cough, sneeze, or use a tissue Waterless hand cleaning with an alcohol-
♦ Before and after any contact with your mouth based gel, lotion, or foam has been proved safe for
or mucous membrane, such as eating, drink-
ing, smoking, applying lip balm, or inserting
or removing contact lenses
The recommended method for handwashing
is based on the following principles; they should
be observed whenever hands are washed:
♦ Soap is used as a cleansing agent because it
aids in the removal of germs through its sudsy
action and alkali content. Pathogens are
trapped in the soapsuds and rinsed away. Liq-
uid soap from a dispenser should be used
whenever possible because bar soap can con-
tain microorganisms. Image not available due to copyright restrictions
♦ Warm water should be used. This is less dam-
aging to the skin than hot water. It also creates
a better lather with soap than does cold
water.
♦ Friction must be used in addition to soap and
water. This action helps rub off pathogens
from the surface of the skin.
♦ All surfaces on the hands must be cleaned.
This includes the palms, the backs/tops of the
hands, and the areas between the fingers.
♦ Fingertips must be pointed downward. The
downward direction prevents water from get-
ting on the forearms and then running down
to contaminate the clean hands.
use during routine patient care. Its use is recom- the hands be washed with soap and water after
mended when the hands are not visibly dirty and 6–10 cleanings with the alcohol-based product. In
are not contaminated with blood or body fluids addition, if the hands are visibly soiled, or if there
(figure 14-9). Most waterless hand cleaning prod- has been contact with blood or body fluid, the
ucts contain alcohol to provide antisepsis and a hands must be washed with soap and water.
moisturizer to prevent drying of the skin. It is Every health care facility has written policies
important to read the manufacturer’s instructions for hand hygiene as a part of their standard pre-
before using any product. Usually a small amount cautions manual. Health care workers must
of the alcohol-based cleaner is applied to the palm become familiar with and follow these policies to
of the hands. The hands are then rubbed vigor- prevent the spread of infection.
ously so the solution is applied to all surfaces of
the hands, fingers, nails, and wrists. The hands STUDENT: Go to the workbook and complete
should be rubbed until they are dry, usually at least the assignment sheet for 14:3, Washing Hands.
15 seconds. Most manufacturers recommend that Then return and continue with the procedure.
PROCEDURE 14:3
forearms and then running back down
Washing Hands to contaminate hands.
4. Use soap to get a lather on your hands.
5. Put the palms of your hands together
Paper towels, running water, waste container, and rub them using friction and a circu-
hand brush or orange/cuticle stick, soap lar motion for at least 15 seconds.
Procedure 6. Put the palm of one hand on the back of

the other hand. Rub together several
1. Assemble all equipment. Stand back times. Repeat this after reversing posi-
slightly from the sink so you do not con- tion of hands (figure 14-10B).
taminate your uniform or clothing. 7. Interlace the fingers on both hands and
Avoid touching the inside of the sink rub them back and forth (figure 14-10C).
with your hands since it is considered
8. Encircle your wrist with the palm and
contaminated. Remove any rings and
fingers of the opposite hand. Use a cir-
push your wristwatch up above your
cular motion to clean the front, back,
wrist.
and sides of the wrist. Repeat for the
2. Turn the faucet on by holding a paper opposite wrist.
towel between your hand and the faucet
9. Clean the nails with an orange/cuticle
(figure 14-10A). Regulate the tempera-
stick and/or hand brush if they are visi-
ture of the water and let water flow over
bly dirty or if this is the first hand clean-
your hands. Discard the towel in the
ing of the day (figures 14-10D and E). If
waste container.
the nails are not visibly dirty, they can
NOTE: Water should be warm. be cleaned by rubbing them against the
CAUTION: Hot water will burn your palm of the opposite hand.
hands. CAUTION: Use the blunt end of orange/
3. With your fingertips pointing down- cuticle stick to avoid injury.
ward, wet your hands. NOTE: Steps 3 through 9 ensure that all
NOTE: Washing in a downward direc- parts of both hands are clean.
tion prevents water from getting on the
362 CHAPTER 14
PROCEDURE 14:3
FIGURE 14-10A Use a dry FIGURE 14-10B Point the FIGURE 14-10C Interlace
towel to turn the faucet on. fingertips downward and use the the fingers to clean between
palm of one hand to clean the the fingers.
back of the other hand.
FIGURE 14-10D The blunt FIGURE 14-10E A hand FIGURE 14-10F With the
end of an orange stick can be brush can also be used to clean fingertips pointing downward,
used to clean the nails. the nails. rinse the hands thoroughly.
10. Rinse your hands from the forearms
down to the fingertips, keeping finger-
tips pointed downward (figure 14-10F).
11. Use a clean paper towel to dry hands
Practice
Go to the workbook and use the
thoroughly, from tips of fingers to wrist. evaluation sheet for 14:3, Washing
Discard the towel in the waste con- Hands, to practice this procedure.
tainer. When you believe you have
12. Use another dry paper towel to turn off mastered this skill, sign the sheet
the faucet. and give it to your instructor for
CAUTION: Wet towels allow passage of further action.
pathogens.
13. Discard all used towels in the waste con-
tainer. Leave the area neat and clean.
Final Checkpoint Using the criteria
14. Apply a water-based hand lotion if listed on the evaluation sheet, your
desired. instructor will grade your performance.
face that comes in contact with blood or infec-

14:4 Information tious materials, and dispose of infectious
waste correctly.
Observing Standard Precautions
♦ Enforce rules of no eating, drinking, smoking,
To prevent the spread of pathogens and applying cosmetics or lip balm, handling con-
disease, the chain of infection must be tact lenses, and mouth pipetting or suctioning
broken. The standard precautions discussed in in any area that can be potentially contami-
this unit are an important way health care work- nated by blood or other body fluids.
ers can break this chain.
♦ Provide appropriate containers that are color
coded (fluorescent orange or orange-red) and
labeled for contaminated sharps (needles,
BLOODBORNE scalpels) and other infectious or biohazard
PATHOGENS STANDARD wastes.
♦ Post signs at the entrance to work areas where
One of the main ways that pathogens are spread there is occupational exposure to biohazard-
is by blood and body fluids. Three pathogens of ous materials. Label any item that is biohaz-
major concern are the hepatitis B virus (HBV), ardous with the red biohazard symbol (figure
the hepatitis C virus (HCV), and the human 14-11). The label must show both the symbol
immunodeficiency virus (HIV), which causes and the word “biohazard.”
AIDS. Consequently, extreme care must be taken ♦ Provide a confidential medical evaluation and
at all times when an area, object, or person is follow-up for any employee who has an expo-
contaminated with blood or body fluids. In 1991, sure incident. Examples might include an
the Occupational Safety and Health Administra- accidental needlestick or the splashing of
tion (OSHA) established Bloodborne Pathogen blood or body fluids on the skin, eyes, or
Standards that must be followed by all health care mucous membranes.
facilities. The employer faces civil penalties if the
regulations are not implemented by the employer ♦ Provide training about the regulations and all
and followed by the employees. These regulations potential biohazards to all employees at no
require all health care facility employers to: cost during working hours, and provide addi-
tional education as needed when procedures
♦ Develop a written exposure control plan, and or working conditions are changed or modi-
update it annually, to minimize or eliminate fied.
employee exposure to bloodborne pathogens.
♦ Identify all employees who have occupational
exposure to blood or potentially infectious NEEDLESTICK SAFETY
materials such as semen, vaginal secretions,
and other body fluids.
ACT
♦ Provide hepatitis B vaccine free of charge to all In 2001, OSHA revised its Bloodborne Pathogen
employees who have occupational exposure, Standards in response to Congress passing the
and obtain a written release form signed by Needlestick Safety and Prevention Act in Novem-
any employee who does not want the vac-
cine.
♦ Provide personal protective equipment
(PPE) such as gloves, gowns, lab coats, masks,
and face shields in appropriate sizes and in
accessible locations.
♦ Provide adequate handwashing facilities and
supplies.
♦ Ensure that the worksite is maintained in a
clean and sanitary condition, follow measures FIGURE 14-11 The universal biohazard symbol
for immediate decontamination of any sur- indicates a potential source of infection.
364 CHAPTER 14
ber 2000. This act was passed after the Centers for ♦ Incorporate changes in annual update of expo-
Disease Control and Prevention (CDC) estimated sure control plan. Employers must include
that 600,000 to 800,000 needlesticks occur each changes in technology that eliminate or reduce
year, exposing health care workers to bloodborne exposure to bloodborne pathogens in the
pathogens. Employers are required to: annual update and document the implemen-
♦ Identify and use effective and safer medical tation of any safer medical devices.
devices. OSHA defines safer devices as sharps ♦ Solicit input from nonmanagerial employees
with engineered injury protections and who are responsible for direct patient care.
includes, but is not limited to, devices such as Employees who provide patient care, and are
syringes with a sliding sheath that shields the exposed to injuries from contaminated sharps,
needle after use, needles that retract into a must be included in a multidisciplinary team
syringe after use, shielded or retracting cath- that identifies, evaluates, and selects safer
eters that can be used to administer intrave- medical devices, and determines safer work
nous medications or fluids, and intravenous practice controls.
systems that administer medication or fluids ♦ Maintain a sharps injury log. Employers with
through a catheter port or connector site using more than 11 employees must maintain a
a needle housed in a protective covering (fig- sharps injury log to help identify high-risk
ure 14-12). OSHA also encourages the use of areas and evaluate ways of decreasing inju-
needleless systems, which include, but are not ries. Each injury recorded must protect the
limited to, intravenous medication delivery confidentiality of the injured employee, but
systems that administer medication or fluids must state the type and brand of device
through a catheter port or connector site using involved in the incident, the work area or
a blunt cannula or other non-needle connec- department where the exposure injury
tion, and jet injection systems that deliver occurred, and a description of how the inci-
subcutaneous or intramuscular injections dent occurred.
through the skin without using a needle.
STANDARD
PRECAUTIONS
Employers are also required to make sure that
every employee uses standard precautions at all
times to prevent contact with blood or other
potentially infectious materials. Standard pre-
cautions (figure 14-13) are rules developed by
the CDC. According to standard precautions,
every body fluid must be considered a potentially
infectious material, and all patients must be con-
sidered potential sources of infection, regardless
of their disease or diagnosis. Standard precau-
tions must be used in any situation where health
care providers may contact:
♦ Blood or any fluid that may contain blood
♦ Body fluids, secretions, and excretions, such
as mucus, sputum, saliva, cerebrospinal fluid,
urine, feces, vomitus, amniotic fluid (sur-
FIGURE 14-12 The Safety-Glide syringe is one rounding a fetus), synovial (joint) fluid, pleu-
example of a safer device to prevent needlesticks. ral (lung) fluid, pericardial (heart) fluid,
(Photo reprinted courtesy of BD [Becton Dickinson peritoneal (abdominal cavity) fluid, semen,
and Company]) and vaginal secretions
FIGURE 14-13 Standard precautions must be observed while working with all patients. (Courtesy of Brevis
Corporation)
366 CHAPTER 14
♦ Mucous membranes Care must be taken while removing gloves to

avoid contamination of the skin. Gloves must
♦ Nonintact skin not be washed or disinfected for reuse because
♦ Tissue or cell specimens washing may allow penetration of liquids
The basic rules of standard precautions through undetected holes, and disinfecting
include: agents may cause deterioration of gloves.
♦ Handwashing: Hands must be washed before ♦ Gowns: Gowns must be worn during any pro-
and after contact with any patient. If hands or cedure that is likely to cause splashing or
other skin surfaces are contaminated with spraying of blood, body fluids, secretions, or
blood, body fluids, secretions, or excretions, excretions. This helps prevent contamination
they must be washed immediately and thor- of clothing or uniforms. Contaminated gowns
oughly with soap and water. Hands must must be handled according to agency policy
always be washed immediately before don- and local and state laws. Wash hands immedi-
ning and immediately after removal of gloves. ately after removing a gown.
♦ Gloves: Gloves (figure 14-14) must be worn ♦ Masks and Eye Protection: Masks and protec-
whenever contact with blood, body fluids, tive eyewear or face shields (figure 14-15) must
secretions, excretions, mucous membranes, be worn during procedures that may produce
tissue specimens, or nonintact skin is possi- splashes or sprays of blood, body fluids, secre-
ble; when handling or cleaning any contami- tions, or excretions. Examples include irriga-
nated items or surfaces; when performing any
invasive (entering the body) procedure; and
when performing venipuncture or blood tests.
Rings must be removed before putting on
gloves to avoid puncturing the gloves. Gloves
must be changed after contact with each
patient and even between tasks or procedures
on the same patient if there is any chance the
gloves are contaminated. Hands must be
washed immediately after removal of gloves.
FIGURE 14-15 Gloves, a gown, a mask, and

FIGURE 14-14 Gloves must be worn whenever protective eyewear must be worn during any
contact with blood, body fluids, secretions, excre- procedure that may produce droplets or cause
tions, mucous membranes, or nonintact skin is splashing of blood, body fluids, secretions, or
possible. excretions.
tion of wounds, suctioning, dental procedures, labeled with a red biohazard symbol. Surgical
delivery of a baby, and surgical procedures. blades, razors, and other sharp objects must
This prevents exposure of the mucous mem- also be discarded in the sharps container.
branes of the mouth, nose, and eyes to any The sharps containers must not be emp-
pathogens. tied or reused. Federal, state, and local
Masks must be used once and then dis- laws establish regulations for the disposal of
carded. In addition, masks should be changed sharps containers. In some areas, the filled
every 30 minutes or anytime they become container is placed in a special oven and
moist or wet. They should be removed by melted. The material remaining is packaged as
grasping the ties or elastic strap. Hands must biohazard or infectious waste and disposed of
be washed immediately after the mask is according to legal requirements for infectious
removed. Protective eyewear or face shields waste.
should provide protection for the front, top,
♦ Spills or Splashes: Spills or splashes of blood,
bottom, and sides of the eyes. If eyewear is not
body fluids, secretions, or excretions must be
disposable, it must be cleaned and disinfected
wiped up immediately (figure 14-17). Gloves
before it is reused.
must be worn while wiping up the area with
♦ Sharps: To avoid accidental cuts or punc- disposable cleaning cloths. The area must
tures, extreme care must be taken while then be cleaned with a disinfectant solution
handling sharp objects. Whenever possible, such as a 10-percent bleach solution. Furni-
safe needles or needleless devices must be ture or equipment contaminated by the spill
used. Disposable needles must never be bent or splash must be cleaned and disinfected
or broken after use. They must be left uncapped immediately. For large spills, an absorbent
and attached to the syringe and placed in a powder may be used to soak up the fluid. After
leakproof puncture-resistant sharps container the fluid is absorbed, it is swept up and placed
(figure 14-16). The sharps container must be in an infectious waste container.
FIGURE 14-16 All needles and sharp objects FIGURE 14-17 Gloves must be worn while wiping
must be discarded immediately in a leakproof up any spills of blood, body fluids, secretions, or
puncture-resistant sharps container. excretions.
368 CHAPTER 14
♦ Resuscitation Devices: Whenever possible, container (figure 14-19) and know the require-
mouthpieces or resuscitation devices should ments for disposal. Soiled linen should be
be used to avoid the need for mouth-to-mouth placed in laundry bags to prevent any con-
resuscitation. These devices should be placed tamination. Linen soiled with blood, body flu-
in convenient locations and be readily acces- ids, or excretions is placed in a special bag for
sible for use. contaminated linen and is usually soaked in a
disinfectant prior to being laundered. Gloves
♦ Waste and Linen Disposal: Health care work- must be worn while handling any contami-
ers must wear gloves and follow the agency
nated linen, and any bag containing contami-
policy developed according to law to dispose
nated linen must be clearly labeled and color
of waste and soiled linen. Infectious wastes
coded.
such as contaminated dressings; gloves; uri-
nary drainage bags; incontinent pads; vaginal ♦ Injuries: Any cut, injury, needlestick, or splash-
pads; disposable emesis basins, bedpans, ing of blood or body fluids must be reported
and/or urinals; and body tissues must be immediately. Agency policy must be followed
placed in special infectious waste or biohaz- to deal with the injury or contamination. Every
ardous material bags (figure 14-18) according health care facility must have a policy for stat-
to law. Other trash is frequently placed in plas- ing actions that must be taken immediately
tic bags and incinerated. The health care when exposure or injury occurs, reporting any
worker must dispose of waste in the proper incident, documenting any exposure incident,
recording the care given, noting follow-up to
the exposure incident, and identifying ways to
prevent a similar incident.
Standard precautions must be followed at all
times by all health care workers. By observing
these precautions, health care workers can help
break the chain of infection and protect them-
selves, their patients, and all other individuals.

the assignment sheet for 14:4, Observing Standard
Precautions. Then return and continue with the
procedure.
FIGURE 14-18 All infectious wastes must be FIGURE 14-19 The health care worker must
placed in special infectious waste or biohazardous know the requirements for disposal of waste materi-
material bags. als and dispose of wastes in the proper containers.
PROCEDURE 14:4
4. Name four instances when gloves must
Observing Standard be worn to observe standard precau-
Precautions tions. Put on a pair of disposable gloves.
Practice removing the gloves without
Equipment and Supplies contaminating the skin. With a gloved
hand, grasp the cuff of the glove on the
Disposable gloves, infectious waste bags, nee- opposite hand, handling only the out-
dle and syringe, sharps container, gown, masks, side of the glove (figure 14-20A). Pull the
protective eyewear, resuscitation devices glove down and turn it inside out while
NOTE: This procedure will help you removing it. Take care not to touch the
learn standard precautions. It is impor- skin with the gloved hand. Using the
tant for you to observe these precautions at ungloved hand, slip the fingers under
all times while working in the laboratory or the cuff of the glove on the opposite
clinical area. hand (figure 14-20B). Touching only the
inside of the glove and taking care not to
Procedure touch the skin, pull the glove down and
turn it inside out while removing it. Place
1. Assemble equipment. the gloves in an infectious waste con-
tainer. Wash your hands immediately.
2. Review the precautions in the informa-
tion section for Observing Standard Pre- 5. Practice putting on a gown. State when
cautions. Note points that are not clear, a gown is to be worn. To remove the
and ask your instructor for an explana- gown, touch only the inside. Fold the
tion. contaminated gown so the outside is
folded inward. Roll it into a bundle and
3. Practice handwashing according to Pro-
place it in an infectious waste container
cedure 14:3. Identify at least six times
if it is disposable, or in a bag for contam-
that hands must be washed according
inated linen if it is not disposable.
to standard precautions.
FIGURE 14-20A To remove the first glove, FIGURE 14-20B To remove the second
use a gloved hand to grasp the outside of the glove, slip the fingers of the ungloved hand
glove on the opposite hand. Pull the glove down inside the cuff of the glove. Touch only the inside
and turn it inside out while removing it. of the glove while pulling it down and turning it
inside out.
370 CHAPTER 14
PROCEDURE 14:4
CAUTION: If a gown is contaminated, remove your gloves, and wash your
gloves should be worn while removing hands.
the gown.
9. Practice handling an infectious waste
NOTE: Folding the gown and rolling it bag. Fold down the top edge of the bag to
prevents transmission of pathogens. form a cuff at the top of the bag. Wear
gloves to close the bag after contami-
6. Practice putting on a mask and protec-
nated wastes have been placed in it. Put
tive eyewear. To remove the mask, han-
your hands under the folded cuff (figure
dle it by the ties only. Clean and disinfect
14-21A) and gently expel excess air from
protective eyewear after use.
the bag. Twist the top of the bag shut and
7. Practice proper disposal of sharps. fold down the top edges to seal the bag.
Uncap a needle attached to a syringe, Secure the fold with tape or a tie accord-
taking care not to stick yourself with the ing to agency policy (figure 14-21B).
needle. Place the entire needle and
10. Examine mouthpieces and resuscita-
syringe in a sharps container. State the
tion devices that can be used in place of
rules regarding disposal of the sharps
mouth-to-mouth resuscitation. You will
container.
be taught to use these devices when you
8. Spill a small amount of water on a coun- learn cardiopulmonary resuscitation
ter. Pretend that it is blood. Put on gloves (CPR).
and use disposable cloths or gauze to
11. Discuss the following situations with
wipe up the spill. Put the contaminated
another student and determine which
cloths or gauze in an infectious waste
standard precautions should be ob-
bag. Use clean disposable cloths or
served:
gauze to wipe the area thoroughly with
a disinfectant agent. Put the cloths or • A patient has an open sore on the skin
gauze in the infectious waste bag, and pus is seeping from the area. You
are going to bathe the patient.
• You are cleaning a tray of instruments
that contains a disposable surgical
blade and needle with syringe.
FIGURE 14-21A To close an infectious waste FIGURE 14-21B After folding down the top
bag, wear gloves and place your hands under edge of the infectious waste bag, tie or tape it
the cuff to gently expel excess air. securely.
PROCEDURE 14:4
• A tube of blood drops to the floor and
breaks, spilling the blood on the floor.
• Drainage from dressings on an
infected wound has soiled the linen
Practice
on the bed you are changing. evaluation sheet for 14:4, Observing
• You work in a dental office and are Standard Precautions. When you
assisting a dentist while a tooth is believe you have mastered this skill,
being extracted (removed). sign the sheet and give it to your

listed on the evaluation sheet, your
instructor will grade your performance.
and it will destroy all microorganisms, both

14:5 Information pathogenic and nonpathogenic, including spores
and viruses.
Sterilizing with an Autoclave Autoclaves are available in various sizes and
Sterilization of instruments and equipment is types. Offices and health clinics usually have
essential in preventing the spread of infection. In smaller units, and hospitals or surgical areas have
any of the health fields, you may be responsible large floor model units. A pressure cooker can be
for proper sterilization. The following basic prin- used in home situations.
ciples relate to sterilization methods. The auto- Before any equipment or supplies are steril-
clave is the safest, most efficient sterilization ized in an autoclave, they must be prepared prop-
method. erly. All items must be washed thoroughly and
An autoclave is a piece of equipment that then rinsed. Oily substances can often be removed
uses steam under pressure or gas to sterilize with alcohol or ether. Any residue left on articles
equipment and supplies (figure 14-22). It is the will tend to bake and stick to the article during
most efficient method of sterilizing most articles, the autoclaving process.
Items that are to remain sterile must be
wrapped before they are autoclaved. A wide vari-
ety of wraps are available. The wrap must be a
material that will allow for the penetration of
steam during the autoclaving process. Samples of
wraps include muslin, autoclave paper, special
plastic or paper bags, and autoclave containers
(figure 14-23).
Autoclave indicators are used to ensure that
articles have been sterilized (figure 14-24). Exam-
ples of indicators include autoclave tape, sensi-
tivity marks on bags or wraps, and indicator
capsules. The indicator is usually placed on or
near the article when the article is put into the
autoclave. Indicators can also be placed in the
center of a package, such as a tray of instruments,
FIGURE 14-22 An autoclave uses steam under to show that sterilization of the entire package
pressure to sterilize items. has occurred. The indicator will change appear-
372 CHAPTER 14
the top of the chamber and moves downward. As

it moves down, it pushes cool, dry air out of the
bottom of the chamber. Therefore, materials
must be placed so the steam can penetrate along
the natural planes between the packages of arti-
cles in the autoclave. Place the articles in such a
way that there is space between all pieces. Pack-
ages should be placed on the sides, not flat. Jars,
basins, and cans should be placed on their sides,
not flat, so that steam can enter and air can flow
out. No articles should come in contact with the
sides, top, or door of the autoclave.
The length of time and amount of pressure
required to sterilize different items varies (figure
14-25). It is important to check the directions that
come with the autoclave. Because different types
of articles require different times and pressures,
it is important to separate loads so that all articles
sterilized at one time require the same time and
pressure. For example, rubber tubings usually
require a relatively short period of time and can
FIGURE 14-23 Special plastic or paper autoclave Articles Time at

bags can be used to sterilize instruments. 250° to 254°F
(121° to 123°C)
Glassware: empty, inverted 15 minutes

Instruments: metal in covered or
open, padded or unpadded tray
Needles, unwrapped
Syringes: unassembled, unwrapped
Instruments, metal combined with
other materials in covered and/or
padded tray
Instruments wrapped in double- 20 minutes
thickness muslin
Flasked solutions, 75–250 mL
Needles, individually packaged in
glass tubes or paper
FIGURE 14-24 Autoclave indicators change color Syringes: unassembled, individually 30 minutes
to show that sterilization has occurred. The strips
packed in muslin or paper
below each package show how the indicators
Dressings wrapped in paper or
looked before sterilization.
muslin (small packs only)
ance during the autoclaving process because of Flasked solutions, 500–1,000 mL
time and temperature, which leads to steriliza- Sutures: silk, cotton, or nylon;
tion. Learn how to recognize that an article is wrapped in paper or muslin
sterile by reading the directions provided with Treatment trays wrapped in
indicators. muslin or paper
The autoclave must be loaded correctly for all FIGURE 14-25 The length of time required to
parts of an article to be sterilized. Steam builds at sterilize different items varies.
be damaged by long exposure. Certain instru- for sterilizing instruments that may corrode, such
ments and needles require a longer period of time as knife blades, or items that would be destroyed
to ensure sterilization; therefore, items of this by the moisture in steam sterilization, such as
type should not be sterilized in the same load as powders. Dry heat should never be used on soft
are rubber tubings. rubber goods because the heat will destroy the
Wet surfaces permit rapid infiltration of rubber. Some types of plastic will also melt in dry
organisms, so it is important that all items are heat. An oven can be used for dry-heat steriliza-
thoroughly dry before being removed from the tion in home situations.
autoclave. The length of time for drying varies. Procedures 14:5A and 14:5B describe wrap-
Follow the manufacturer’s instructions. ping articles for autoclaving and autoclaving
Sterilized items must be stored in clean, dust- techniques. These procedures vary in different
proof areas. Items usually remain sterile for 30 agencies and areas, but the same principles apply.
days after autoclaving. However, if the wraps In some facilities, many supplies are purchased
loosen or tear, if they become wet, or if any chance as sterile, disposable items; needles and syringes
of contamination occurs, the items should be are purchased in sterilized wraps, used once, and
rewrapped and autoclaved again. then destroyed. In other facilities, however, spe-
NOTE: At the end of the 30-day sterile period— cial treatment trays are sterilized and used more
providing that the wrap has not loosened, been than one time.
torn, or gotten wet—remove the old autoclave It is important that you follow the directions
tape from the package, replace with a new, dated specific to the autoclave with which you are
tape, and resterilize according to correct proce- working as well as the agency policy for sterile
dure. supplies. Careless autoclaving permits the trans-
Some autoclaves are equipped with a special mission of disease-producing organisms. Infec-
door that allows the autoclave to be used as a dry- tion control is everyone’s responsibility.
heat sterilizer. Dry heat involves the use of a high
temperature for a long period of time. The tem- STUDENT: Go to the workbook and complete
perature is usually a minimum of 320–350°F the assignment sheet for 14:5, Sterilizing with an
(160–177°C). The minimum time is usually 60 Autoclave. Then return and continue with the pro-
minutes. Dry-heat sterilization is a good method cedures.
PROCEDURE 14:5A
CAUTION: If the items to be autoclaved
Wrapping Items are contaminated with blood, body flu-
for Autoclaving ids, or tissues, gloves must be worn
while cleaning the items.
Equipment and Supplies 3. Sanitize the items to be sterilized. Instru-
ments, bowls, and similar items should
Items to wrap: instrument, towel, bowl; auto-
be cleaned thoroughly in soapy water
clave wrap: paper, muslin, plastic or paper
(figure 14-26). Rinse the items well in
bag; autoclave tape or indicator; disposable
cool water to remove any soapy residue.
or utility gloves; pen or autoclave marker;
Then rinse well with hot water. Dry the
masking tape (if autoclave tape is not used)
items with a towel. After the items are
sanitized and dry, remove the gloves and
Procedure wash hands.
1. Assemble equipment. NOTE: If stubborn stains are present, it
may be necessary to soak the items.
2. Wash hands. Put on gloves.
374 CHAPTER 14
PROCEDURE 14:5A
end until a compact package is formed
(figure 14-27A). All folds should be the
same size. Fold back one corner on the
top fold (figure 14-27B). This provides a
piece to grab when opening the linen.
NOTE: Fanfolding linens allows for easy
handling after sterilization.
5. Select the correct wrap for the item.
Make sure the wrap is large enough to
enclose the item to be wrapped.
NOTE: Double-thickness muslin, dis-
posable paper wraps, and plastic or
paper bags are the most common
wraps.
6. With the wrap positioned at a diagonal
FIGURE 14-26 Wear gloves to scrub instru- angle and one corner pointing toward
ments thoroughly with soapy water. you, place the item to be sterilized in the
center of the wrap.
NOTE: Check the teeth on serrated
NOTE: Make sure that hinged instru-
(notched like a saw) instruments. Scrub
ments are open so the steam can steril-
with a brush as necessary.
ize all edges.
4. To prepare linen for wrapping, check
7. Fold up the bottom corner to the center
first to make sure it is clean and dry. Fold
(figure 14-28A). Double back a small
the linen in half lengthwise. If it is very
corner (figure 14-28B).
wide, fold lengthwise again. Fanfold or
accordion pleat the linen from end to 8. Fold a side corner over to the center.
Make sure the edges are sealed and that
there are no air pockets. Bring back a
small corner (figure 14-28C).
FIGURE 14-27A Fanfold clean, dry linen so FIGURE 14-27B Fold back one corner on the
all the folds are the same size. top fold of the linen.
PROCEDURE 14:5A
FIGURE 14-28A Place the FIGURE 14-28B Turn a small FIGURE 14-28C Fold in one
instrument in the center of the corner back to form a tab. side and fold back a tab.
wrap. Fold the bottom corner in
to the center.
FIGURE 14-28D Fold in the FIGURE 14-28E Bring the FIGURE 14-28F Secure the
opposite side and fold back a final corner up and over the top package with autoclave tape.
tab. of the pack and tuck it in, leaving Label it with the date, contents,
a small corner exposed. and your initials.
376 CHAPTER 14
PROCEDURE 14:5A
CAUTION: Any open areas at corners 13. Check the package. It should be firm
will allow pathogens to enter. enough for handling but loose enough
for proper circulation of steam.
9. Fold in the other side corner. Again,
watch for and avoid open edges. Bring 14. To use a plastic or paper autoclave bag
back a small corner (figure 14-28D). (refer to figure 14-23), select or cut the
correct size for the item to be sterilized.
10. Bring the final corner up and over the
Place the clean item inside the bag.
top of the package. Check the two edges
Double fold the open end(s) and tape or
to be sure they are sealed and tight. Tuck
secure with autoclave tape. Check the
this under the pocket created by the
package to make sure it is secure.
previous folds. Leave a small corner
exposed so it can be used when unwrap- NOTE: In some agencies, the ends are
ping the package (figure 14-28E). sealed with heat prior to autoclaving.
NOTE: This is frequently called an “enve- NOTE: If the bag has an autoclave indi-
lope” wrap, because the final corner is cator, regular masking tape can be used
tucked into the wrap similar to the way to seal the ends.
the flap is tucked into an envelope.
11. Secure with autoclave or pressure-
16. Wash hands.
sensitive indicator tape.
NOTE: If regular masking tape is used,
attach an autoclave indicator to reflect
when contents are sterilized.
12. Label the package by marking the
Practice
tape with the date and contents (figure
evaluation sheet for 14:5A,
14-28F). Some health care agencies may
require you to initial the label. Wrapping Items for Autoclaving, to
practice this procedure. When you
NOTE: For certain items, the type or size believe you have mastered this skill,
of item should be noted, for example, sign the sheet and give it to your
curved hemostat or mosquito hemostat, instructor for further action.
hand towel or bath towel, small bowl or
large bowl.
NOTE: Contents will not be sterile after Final Checkpoint Using the criteria
30 days, so the date of sterilization must listed on the evaluation sheet, your
be noted on the package. instructor will grade your performance.
PROCEDURE 14:5B
or to the level indicated on the auto-
Loading and Operating clave.
an Autoclave NOTE: Distilled water prevents the col-
NOTE: Follow the operating instructions for lection of mineral deposits and prolongs
your autoclave. The basic principles of load- the life and effectiveness of the auto-
ing apply to all autoclaves. Basic controls for clave.
one autoclave are shown in figure 14-29.
5. Check the pressure gauge to make sure
it is at zero.
CAUTION: Never open the door unless
Autoclave, distilled water, small pitcher or the pressure is zero.
measuring cup, items wrapped or prepared
for autoclaving, time chart for autoclave, 14:5 6. Open the safety door by following the
Information section manufacturer’s instructions. Some door
handles require an upward and inward
Procedure pressure; others require a side-pressure
technique.
Review the Information section for 14:5, Steril-
7. Load the autoclave. Make sure all arti-
izing with an Autoclave. Then proceed with
cles have been prepared correctly. Check
the following activities. You should read
for autoclave indicators, secure wraps,
through the procedure first, checking against
and correct labels. Separate loads so all
the diagram. Then practice with an autoclave.
items require the same time, tempera-
1. Assemble equipment. ture, and pressure. Place packages on
their sides. Place bowls or basins on
2. Wash and dry hands thoroughly.
their sides so air and steam can flow in
3. Check the three-prong plug and the and out of the container (figure 14-30).
electrical cord. If either is damaged or Make sure there is space between the
prongs are missing, do not use the auto- packages so the steam can circulate.
clave. If no problems are present, plug
NOTE: Check to make sure no large
the cord into a wall outlet.
packages block the steam flow to smaller
4. Use distilled water to fill the reservoir to packages. Place large packages on the
within 2 1/2 inches below the opening bottom.
(A) (B)
FIGURE 14-30 Bowls or basins should be
placed on their sides in the autoclave so air and
FIGURE 14-29 Autoclave control valves vary, steam can flow in and out of the container: (A)
but most contain the same basic controls. incorrect placement; (B) correct placement.
378 CHAPTER 14
PROCEDURE 14:5B
CAUTION: Make sure no item comes in 17. When the required time has passed, set
contact with the sides, top, or door of the controls so the autoclave will vent
the autoclave chamber. the steam from the chamber.
8. Follow the instructions for filling the 18. Put on safety glasses.
chamber with the correct amount of CAUTION: Never open the door without
water. Most autoclaves have a “Fill” set- glasses. The escaping steam can burn
ting on the control. Allow water to enter the eyes.
the chamber until the water covers the 19. Check the pressure and temperature
fill plate inside the chamber. gauges. When the pressure gauge is at
9. When the correct amount of water is in zero, and the temperature gauge is at or
the chamber, follow the instructions for below 212°F, open the door about 1/2 to
stopping the flow of water. In many 1 inch to permit thorough drying of con-
autoclaves, turning the control valve to tents.
“Sterilize” stops the flow of water from CAUTION: Do not open the door until
the reservoir. pressure is zero.
10. Check the load in the chamber to be NOTE: Most autoclaves have a safety
sure it is properly spaced. The chamber lock on the door that does not release
can also be loaded at this point, if this until the pressure is at zero.
has not been done previously. 20. After the autoclaved items are com-
11. Close and lock the door. pletely dry, remove and store them in a
CAUTION: Be sure the door is securely dry, dust-free area.
locked; check by pulling slightly. CAUTION: Handle supplies and equip-
12. Read the time chart for the specific time ment carefully. They may be hot.
and temperature required for steriliza- 21. If there are additional loads to run, leave
tion of items that were placed in the the main valve in the vent position. This
autoclave. will keep the autoclave ready for imme-
13. After referring to the chart provided with diate use.
the autoclave or reviewing figure 14-25, 22. If this is the final load, turn the auto-
set the control valves to allow the tem- clave off. Unplug the cord from the wall
perature and pressure to increase in the outlet; do not pull on the cord.
autoclave. NOTE: The autoclave must be cleaned
14. When the desired temperature (usually on a regular basis. Follow manufactur-
250–254°F or 121–123°C) and pressure er’s instructions.
(usually 15 pounds) have been reached, 23. Replace all equipment used.
set the controls to maintain the desired 24. Wash hands.
temperature during the sterilization
process. Follow the manufacturer’s
instructions.
15. Based on the information in the time
Practice
chart, set the timer to the correct time. Go to the workbook and use the
evaluation sheet for 14:5B, Loading
NOTE: Many autoclaves require you to and Operating an Autoclave, to
rotate the timer past 10 (minutes) before
setting the time.
16. Check the pressure and temperature sign the sheet and give it to your
gauges at intervals to make sure they instructor for further action.
remain as originally set.
NOTE: Most autoclaves automatically Final Checkpoint Using the criteria
shut off when pressure reaches 35 listed on the evaluation sheet, your
pounds. instructor will grade your performance.
also specify the recommended time for the most

14:6 Information thorough disinfection.
Chemical solutions can cause rust to form on
Using Chemicals for Disinfection certain instruments, so antirust tablets or solu-
Many health fields require the use of chemicals tions are frequently added to the chemicals.
for aseptic control. Certain points that must be Again, it is important to read the directions pro-
observed while using the chemicals are discussed vided with the tablets or solution. If improperly
in the following section. used, antirust substances may cause a chemical
Chemicals are frequently used for aseptic reaction with a solution and reduce the effective-
control. Many chemicals do not kill spores and ness of the chemical disinfectant.
viruses; therefore, chemicals are not a method of The container used for chemical disinfection
sterilization. Because sterilization does not occur, must be large enough to accommodate the items.
chemical disinfection is the appropriate term In addition, the items should be separate so each
(rather than cold sterilization, a term sometimes one will come in contact with the chemical. A
used). A few chemicals will kill spores and viruses, tight-fitting lid must be placed on the container
but these chemicals frequently require that while the articles are in the solution to prevent
instruments be submerged in the chemical for 10 evaporation that could affect the strength of the
or more hours. It is essential to read an entire solution. The lid also decreases the chance of
label to determine the effectiveness of the prod- dust and airborne particles from falling into the
uct before using any chemical. solution.
Chemicals are used to disinfect instruments The chemical disinfectant must completely
that do not penetrate body tissue. Many dental cover the article. This is the only way to be sure
instruments, percussion hammers, scissors, and that all parts of the article will be disinfected.
similar items are examples. In addition, chemi- Before removing items from solutions, health
cals are used to disinfect thermometers and other workers must wash their hands. Sterile gloves or
items that would be destroyed by the high heat sterile pick-ups or transfer forceps may be used
used in the autoclave. to remove the instruments from the solution. The
Proper cleaning of all instruments or articles items should be rinsed with sterile water to
is essential. Particles or debris on items may con- remove any remaining chemical solution. After
taminate the chemicals and reduce their effec- rinsing, the instruments are placed on a sterile or
tiveness. In addition, all items must be rinsed clean towel to dry, and then stored in a drawer or
thoroughly because the presence of soap can also dust-free closet.
reduce the effectiveness of chemicals. The arti- Solutions must be changed frequently. Some
cles must be dry before being placed in the disin- solutions can be used over a period of time, but
fectant to keep the chemical at its most effective others must be discarded after one use. Follow
strength. the manufacturer’s instructions. However, any
Some chemical solutions used as disinfec- time contamination occurs or dirt is present in
tants are 90-percent isopropyl alcohol, formalde- the solution, discard it. A fresh solution must be
hyde–alcohol, 2-percent phenolic germicide, used.
10-percent bleach (sodium hypochlorite) solu-
tion, glutaraldehyde, iodophor, Lysol, Cidex, and STUDENT: Go to the Workbook and complete
benzalkonium (zephiran). The manufacturer’s the assignment sheet for 14:6, Using Chemicals for
directions should be read completely before Disinfection. Then return and continue with the
using any solution. Some solutions must be procedure.
diluted or mixed before use. The directions will
380 CHAPTER 14
PROCEDURE 14:6
so the solution can flow between the
Using Chemicals for surfaces.
Disinfection 7. Carefully read label instructions about
the chemical solution. Some solutions
Equipment and Supplies must be diluted. Check the manufactur-
er’s recommended soaking time.
Chemicals, container with tight-fitting lid,
basin, soap, water, instruments, brush, sterile CAUTION: Reread instructions to be
pick-ups or transfer forceps, sterile towel, sure solution is safe to use on instru-
sterile gloves, eye protection, disposable ments.
gloves
NOTE: An antirust substance must be
added to some solutions.
Procedure
8. Pour solution into the container slowly
1. Assemble equipment. to avoid splashing. Make sure that all
instruments are covered (figure 14-31).
2. Wash hands. Put on disposable or heavy- Close the lid of the container.
duty utility gloves and eye protection.
NOTE: Read label three times: before
NOTE: Wear gloves if any of the instru- pouring, while pouring, and after pour-
ments or equipment are contaminated ing.
with blood or body fluids. Wear eye pro-
tection if there is any chance splashing CAUTION: Avoid splashing the chemi-
will occur. cal on your skin. Improper handling of
chemicals may cause burns and/or inju-
3. Wash all instruments or equipment ries.
thoroughly. Use warm soapy water. Use
the brush on serrated edges of instru- 9. Remove gloves. Wash hands.
ments. 10. Leave the instruments in the solution
NOTE: All tissue and debris must be for the length of time recommended by
removed from the instrument or item or the manufacturer.
it will not be disinfected.
4. Rinse in cool water to remove soapy res-
idue. Then rinse well with hot water. Dry
all instruments or equipment thor-
oughly.
NOTE: Water on the instruments or
equipment will dilute the chemical dis-
infectant.
5. Check container. Make sure lid fits
securely.
NOTE: A loose cover will permit
entrance of pathogens and/or evapora-
tion of the chemical solution.
6. Place instruments in the container. FIGURE 14-31 Pour the chemical disinfectant
Make sure there is a space between into the container until all instruments are
instruments. Leave hinged edges open covered with solution.
PROCEDURE 14:6
NOTE: Twenty to 30 minutes is the usual 12. Replace all equipment used.
soaking time.
CAUTION: If the disinfectant solution
NOTE: If the solution requires a long can be used again, label the container
period (for example, 10–12 hours) for with the name of the disinfectant, date,
disinfecting, label the container with and number of days it can be used
the date and time the process began, according to manufacturer’s instruc-
ending date and time, and your initials. tions. When solutions cannot be reused,
dispose of the solution according to
11. When instruments have soaked the cor-
manufacturer’s instructions.
rect amount of time, use sterile gloves or
sterile pick-ups or transfer forceps to 13. Remove gloves. Wash hands.
remove the instruments from the solu-
tion. Hold the instruments over a sink or
basin and pour sterile water over them
to rinse them thoroughly. Place them on Practice
a sterile towel to dry. A second sterile Go to the workbook and use the
towel is sometimes used to dry the evaluation sheet for 14:6, Using
instruments or to cover the instruments Chemicals for Disinfection, to
while they are drying. Store the instru- practice this procedure. When you
ments in special drawers, containers, or believe you have mastered this skill,
dust-free closets. sign the sheet and give it to your
NOTE: Some contamination occurs instructor for further action.
when instruments are exposed to the
air. In some cases, such as with external Final Checkpoint Using the criteria
instruments, this minimal contamina- listed on the evaluation sheet, your
tion will not affect usage. instructor will grade your performance.
cles. If sterilization is desired, other methods

14:7 Information must be used after the ultrasonic cleaning.
Only ultrasonic solutions should be used in
Cleaning with an Ultrasonic Unit the unit. Different solutions are available for dif-
Ultrasonic units are used in many dental and ferent materials. A general, all-purpose cleaning
medical offices and other health agencies to solution is usually used in the permanent tank
remove dirt, debris, blood, saliva, and tissue from and to clean many items. There are other specific
a large variety of instruments prior to sterilizing solutions for alginate, plaster and stone removal,
them. Ultrasonic cleaning uses sound waves to and tartar removal. The solution chart provided
clean. When the ultrasonic unit is turned on, the with the ultrasonic unit will state which solution
sound waves produce millions of microscopic should be used. It is important to read labels care-
bubbles in a cleaning solution. When the bubbles fully before using any solutions. Some solutions
strike the items being cleaned, they explode, a must be diluted before use. Some can be used
process known as cavitation, and drive the only on specific materials. All solutions are toxic.
cleaning solution onto the article. Accumulated They can also cause skin irritation, so contact
dirt and residue are easily and gently removed with the skin and eyes should be avoided. Solu-
from the article. tions should be discarded when they become
Ultrasonic cleaning is not sterilization cloudy or contaminated, or if cleaning results are
because spores and viruses remain on the arti- poor.
382 CHAPTER 14
The permanent tank of the ultrasonic unit Many different items can be cleaned in an
(figure 14-32) must contain a solution at all times. ultrasonic unit. Examples include instruments,
A general, all-purpose cleaning solution is used impression trays, glass products, and most jew-
most of the time. Glass beakers or auxiliary pans elry. The ultrasonic unit should not be used on
or baskets can then be placed in the permanent jewelry with pearls or pasted stones. The sound
tank. The items to be cleaned and the proper waves can destroy the pearls or the paste holding
cleaning solution are then put in the beakers or the stones. Prior to cleaning, most of the dirt or
pans. The bottoms of the beakers or pans must particles should be brushed off the items being
always be positioned below the level of the solu- cleaned. It is better to clean a few articles at a
tion present in the permanent tank. In this way, time and avoid overloading the unit. If items are
cavitation can be transmitted from the main tank close together, the process of cavitation is poor
and through the solution to the items being because the bubbles cannot strike all parts of the
cleaned in the beakers or pans. The ultrasonic items being cleaned.
unit should never be operated without solutions The glass beakers used in the ultrasonic unit
in both containers. In addition, the items being are made of a type of glass that allows the passage
cleaned must be submerged in the cleaning solu- of sound waves. After continual use, the sound
tion. waves etch the bottom of the beakers. A white,
opaque coating forms. The beakers must be dis-
carded and replaced when this occurs. After each
use, the beakers should be washed with soap and
Permanent tank Pilot Timer Cleaning water and rinsed thoroughly to remove any soapy
(for beakers and light solution
auxiliary pan) residue. They must be dry before being filled with
Lid solution because water in the beaker can dilute
the solution.
The permanent tank of the unit must be
drained and cleaned at intervals based on tank
use or appearance of the solution in the tank. A
drain valve on the side of the tank is opened to
allow the solution to drain. The tank is then wiped
with a damp cloth or disinfectant. Another damp
cloth or disinfectant is used to wipe off the out-
side of the unit. The unit should never be sub-
merged in water to clean it. After cleaning, a fresh
solution should be placed in the permanent
tank.
The manufacturer’s instructions must be read
carefully before using any ultrasonic unit. Most
Drain manufacturers provide cleaning charts that state
Auxiliary the type of solution and time required for a vari-
pan with ety of cleaning problems. Each time an item is
solution cleaned in an ultrasonic unit, the chart should be
Beaker used to determine the correct cleaning solution
with and time required.
solution
Positioning
cover for STUDENT: Go to the workbook and complete
beakers the assignment sheet for 14:7, Cleaning with an
FIGURE 14-32 Parts of an ultrasonic cleaning Ultrasonic Unit. Then return and continue with
unit. the procedure.
PROCEDURE 14:7
4. Check the permanent tank to be sure it
Cleaning with an has enough cleaning solution. An all-
Ultrasonic Unit purpose cleaning solution is usually
used in this tank.
Equipment and Supplies CAUTION: Never run the unit without
solution in the permanent tank.
Ultrasonic unit, permanent tank with solu-
tion, beakers, auxiliary pan or basket with NOTE: Many solutions must be diluted
covers, beaker bands, cleaning solutions, before use; if new solution is needed,
transfer forceps or pick-ups, paper towels, read the instructions on the bottle.
gloves, brush, soap, water for rinsing, articles
5. Pour the proper cleaning solution into
for cleaning, solution chart
the auxiliary pan or beakers.
Procedure NOTE: Use the cleaning chart to deter-

mine which solution to use.
1. Assemble all equipment. CAUTION: Read label before using.
2. Wash hands. Put on gloves if any CAUTION: Handle solutions carefully.
items are contaminated with Avoid contact with skin and eyes.
blood, body fluids, secretions, or excre-
tions. 6. Place the beakers, basket, or auxiliary
pan into the permanent tank (figures
NOTE: Use heavy-duty utility gloves if 14-33A and B). Use beaker positioning
instruments are sharp. covers and beaker bands. Beaker bands
3. Use a brush and soap and water to are large bands that circle the beakers to
remove any large particles of dirt from hold them in position and keep them
articles to be cleaned. Rinse articles from hitting the bottom of the perma-
thoroughly. Dry items. nent tank.
NOTE: Rinsing is important because
soap may interact with the cleaning
solution.
FIGURE 14-33A The auxiliary basket can be FIGURE 14-33B Glass beakers can be used
used to clean larger items in an ultrasonic unit. to clean smaller items in an ultrasonic unit.
384 CHAPTER 14
PROCEDURE 14:7
7. Check to be sure that the bottoms of the 13. Periodically change solutions in the per-
beakers, basket, or pan are below the manent tank and auxiliary containers.
level of solution in the permanent tank. Do this when solutions become cloudy
or cleaning has not been effective. To
NOTE: For sonic waves to flow through
clean the permanent tank, place a con-
solutions in the beakers, basket, or pan,
tainer under the side drain to collect the
the two solution levels must overlap.
solution. Then open the valve and drain
8. Place articles to be cleaned in the bea- solution from the tank. Wash the inside
kers, basket, or pan. Be sure the solution with a damp cloth or disinfectant. To
completely covers the articles. Do not clean the auxiliary pans or beakers, dis-
get solution on your hands. card the solution. (It can be poured
NOTE: Remember that pearls or pasted down the sink, but allow water to run for
stones cannot be cleaned in an ultra- a time after disposing of the solution.)
sonic unit. Then wash the containers and rinse
thoroughly.
9. Turn the timer past 5 (minutes) and
then set the proper cleaning time. Use NOTE: If the bottoms of beakers are
the cleaning chart to determine the cor- etched and white, the beakers must be
rect amount of time required for the discarded and replaced.
items. Most articles are cleaned in 2–5 14. Clean and replace all equipment used.
minutes. Make sure all beakers are covered with
10. Check that the unit is working. You lids.
should see a series of bubbles in both 15. Wash hands.
solutions. This is called cavitation.
CAUTION: Do not get too close. Solu-
tion can spray into your face and eyes.
Use beaker lids to prevent spray.
11. When the timer stops, cleaning is com-
Practice
plete. Use transfer forceps or pick-ups evaluation sheet for 14:7, Cleaning
to lift articles from the basket, pan, or
with an Ultrasonic Unit, to practice
beakers. Place the articles on paper tow-
els. Then rinse articles thoroughly under
you have mastered this skill, sign
running water.
CAUTION: Avoid contact with skin. instructor for further action.
Solutions are toxic.
12. Allow articles to air-dry or dry them with
paper towels. Inspect the articles for Final Checkpoint Using the criteria
cleanliness. If they are not clean, repeat listed on the evaluation sheet, your
the process. instructor will grade your performance.
Organisms and pathogens travel quickly

14:8 INFORMATION through a wet surface, so the sterile field must be
kept dry. If a sterile towel or article gets wet, con-
Using Sterile Techniques tamination has occurred. It is very important to
Many procedures require the use of sterile tech- use care when pouring solutions into sterile
niques to protect the patient from further infec- bowls or using solutions around a sterile field.
tion. Surgical asepsis refers to procedures that Various techniques can be used to remove
keep an object or area free from living organisms. articles from sterile wraps, depending on the arti-
The main facts are presented here. cle being unwrapped. Some common techniques
Sterile means “free from all organisms,” are the drop, mitten, and transfer-forceps tech-
including spores and viruses. Contaminated niques:
means that organisms and pathogens are pres-
♦ Drop technique: This technique is used for
ent. While working with sterile supplies, it is
gauze pads, dressings, and small items. The
important that correct techniques be followed to
wrapper is partially opened and then held
maintain sterility and avoid contamination. It is
upside down over the sterile field. The item
also important that you are able to recognize
drops out of the wrapper and onto the sterile
sterile surfaces and contaminated surfaces.
field (figure 14-34A). It is important to keep
A clean, uncluttered working area is required
fingers back so the article does not touch the
when working with sterile supplies. A sterile
skin as it falls out of the wrapper. It is also
object must never touch a nonsterile object. If
important to avoid touching the inside of the
other objects are in the way, it is easy to contami-
wrapper.
nate sterile articles. If sterile articles touch the
skin or any part of your clothing, they are no lon- ♦ Mitten technique: This technique is used for
ger sterile. Because any area below the waist is bowls, drapes, linen, and other similar items.
considered contaminated, sterile articles must The wrapper is opened and its loose ends are
be held away from and in front of the body and grasped around the wrist with the opposite
above the waist. hand (figure 14-34B). In this way, a mitten is
Once a sterile field has been set up (for formed around the hand that is still holding
example, a sterile towel has been placed on a the item (for example, a bowl). With the mit-
tray), never reach across the top of the field. ten hand, the item can be placed on the sterile
Microorganisms can drop from your arm or tray.
clothing and contaminate the field. Always reach ♦ Transfer forceps: These are used for cotton
in from either side to place additional articles on balls, small items, or articles that cannot be
the field. Keep the sterile field in constant view. removed by the drop or mitten techniques.
Never turn your back to a sterile field. Avoid Either sterile gloves or sterile transfer forceps
coughing, sneezing, or talking over the sterile (pick-ups) are used. Sterile transfer forceps or
field because airborne particles can fall on the pick-ups are removed from their container of
field and contaminate it. disinfectant solution and used to grasp the
The 2-inch border around the sterile field
(towel-covered tray) is considered contaminated.
Therefore, 2 inches around the outside of the field
must not be used when sterile articles are placed
on the sterile field.
All sterile items must be checked carefully
before they are used. If the item was autoclaved
and dated, most health care facilities believe the
date should not be more than 30 days from auto-
claving. Follow agency guidelines for time limits.
If tears or stains are present on the package, the
item should not be used because it could be con-
taminated. If there are any signs of moisture on
the package, it has been contaminated and FIGURE 14-34A Sterile items can be dropped
should not be used. from the wrapper onto the sterile field.
386 CHAPTER 14
FIGURE 14-34B By using the wrap as a mitten,

sterile supplies can be placed on a sterile field. FIGURE 14-34C Sterile transfer forceps or pick-
ups can be used to grasp sterile items and place
article from the opened package. The item is them on a sterile field.
removed from the opened, sterile wrap and
tant to hold the hands away from the body and
placed on the sterile field (figure 14-34C). The
above the waist to avoid contamination. Handle
transfer forceps must be pointed in a down-
only sterile objects while wearing sterile gloves.
ward direction. If they are pointed upward,
If at any time during a procedure there is any
the solution will flow back to the handle,
suspicion that you have contaminated any article,
become contaminated, and return to contam-
start over. Never take a chance on using contami-
inate the sterile tips when they are being used
nated equipment or supplies.
to pick up items. In addition, care must be
A wide variety of commercially prepared ster-
taken not to touch the sides or rim of the for-
ile supplies is available. Packaged units are often
ceps container while removing or inserting
set up for special procedures, such as changing
the transfer forceps. Also, the transfer forceps
dressings. Many agencies use these units instead
must be shaken gently to get rid of excess dis-
of setting up special trays. Observe all sterile prin-
infectant solution before they are used.
ciples while using these units and read any direc-
Make sure the sterile tray is open and you are tions provided with the units.
ready to do the sterile procedure before putting
the sterile gloves on your hands. Sterile gloves are STUDENT: Go to the workbook and complete
considered sterile on the outside and contami- the assignment sheet for 14:8, Using Sterile Tech-
nated on the inside (side against the skin). Once niques. Then return and continue with the proce-
they have been placed on the hands, it is impor- dures.
PROCEDURE 14:8A
Opening Sterile Procedure
Packages 1. Assemble equipment.
2. Wash hands.
3. Take equipment to the area where it will
Sterile package of equipment or supplies, a be used. Check the autoclave indicator
table or other flat surface, sterile field (tray and date on the package. Check the
with sterile towel) package for stains, tears, moisture, or
PROCEDURE 14:8A
evidence of contamination. Do not use 8. With one hand, raise a side flap and pull
the package if there is any evidence of laterally (sideways) away from the pack-
contamination. age (figure 14-35B).
NOTE: Contents are not considered CAUTION: Do not touch the inside of
sterile if 30 days have elapsed since the wrapper at any time.
autoclaving.
9. With the opposite hand, open the other
4. Pick up the package with the tab or side flap by pulling the tab to the side
sealed edge pointing toward you. If the (figure 14-35C).
item is small, it can be held in the hand
NOTE: Always reach in from the side.
while being unwrapped. If it is large,
Never reach across the top of the sterile
place it on a table or other flat surface.
field or across any opened edges.
5. Loosen the wrapper fastener (usually
10. Open the proximal (closest) flap by lift-
tape).
ing the flap up and toward you. Then
6. Check to be sure the package is away drop it over the front of your hand (or
from your body. If it is on a table, make the table) (figure 14-35D).
sure it is not close to other objects.
CAUTION: Be careful not to touch the
NOTE: Avoid possible contamination by inside of the package or the contents of
keeping sterile supplies away from other the package.
objects.
11. Transfer the contents of the sterile pack-
7. Open the distal (furthest) flap of the age using one of the following tech-
wrapper by grasping the outside of the niques:
wrapper and pulling it away from you
a. Drop: Separate the ends of the wrap
(figure 14-35A).
and pull apart gently (figure 14-36).
CAUTION: Do not reach across the top Avoid touching the inside of the wrap.
of the package. Reach around the pack- Secure the loose ends of the wrap and
age to open it. hold the package upside down over
FIGURE 14-35A To open a sterile package, FIGURE 14-35B Open one side by pulling
open the top flap away from you, handling only the wrap out to the side.
the outside of the wrap.
388 CHAPTER 14
PROCEDURE 14:8A
FIGURE 14-35C Open the opposite side by FIGURE 14-35D Open the side nearest to
pulling the wrap out to the opposite side. you by pulling back on the wrap.
the sterile field. Allow the contents to securely around your wrist. This can
drop onto the sterile tray (refer to fig- be compared to making a mitten of
ure 14-34A). the wrapper (with the sterile equip-
ment on the outside of the mitten).
b. Mitten: Grasp the contents securely
Place the item on the sterile tray or
by holding on to the outside of the
hand it to someone who is wearing
wrapper as you unwrap it. With your
sterile gloves (refer to figure 14-34B).
free hand, gather the loose edges of
the wrapper together and hold them c. Transfer forceps: Remove forceps from
their sterile container, taking care not
to touch the side or rim of the con-
tainer with the forceps (figure 14-37).
Hold the forceps pointed downward.
Shake them gently to remove excess
disinfectant solution. Take care not to
touch anything with the forceps. Use
the forceps to grasp the item in the
package and then place the item on
the sterile tray.
NOTE: The method of transfer depends
on the sterile item being transferred.
NOTE: If at any time during the proce-
dure there is any suspicion that you
have contaminated any article, start
over. Never take a chance on using
equipment for a sterile procedure if
there is any possibility that the equip-
FIGURE 14-36 Separate the ends of the ment is contaminated.
wrap and pull the edges apart gently without
touching the contents. 12. Replace all equipment used.
13. Wash hands.
PROCEDURE 14:8A
Practice
evaluation sheet for 14:8A, Opening
Sterile Packages, to practice this
procedure. When you believe you
have mastered this skill, sign the
sheet and give it to your instructor
for further action.

FIGURE 14-37 Remove the transfer or pick-

up forceps without touching the sides or rim of
the container and point them in a downward
direction.
PROCEDURE 14:8B
3. Check the date and autoclave indicator
Preparing a Sterile for sterility. If more than 30 days have
Dressing Tray elapsed, use another package with a
more recent date. Put the unsterile pack-
Equipment and Supplies age aside for resterilization. Check the
package for stains, tears, moisture, or
Tray or Mayo stand, sterile towels, sterile evidence of contamination. Do not use
basin, sterile cotton balls or gauze sponges, the package if there is any evidence of
sterile dressings (different sizes), antiseptic contamination.
solution, forceps in disinfectant solution
4. Place the tray on a flat surface or a Mayo
stand.
Procedure
NOTE: Make sure the work area is clean
1. Assemble all equipment. and dry, and there is sufficient room to
work.
2. Wash hands.
390 CHAPTER 14
PROCEDURE 14:8B
5. Open the package that contains the up to create a sterile field. Holding on to
sterile towel. Be sure it is held away from the outside edges of the towel, fanfold
your body. Place the wrapper on a sur- the back of the towel so the towel can be
face away from the tray or work area. used later to cover the supplies.
Touch only the outside of the towel. Pick
CAUTION: Do not reach across the top
up the towel at its outer edge. Allow it to
of the sterile field. Reach in from either
open by releasing the fanfolds (figure
side.
14-38A). Place the towel with the outer
side (side you have touched) on the tray NOTE: If you are setting up a relatively
or Mayo stand (figure 14-38B). The large work area, one towel may not be
untouched, or sterile, side will be facing large enough when fanfolded to cover
the supplies. In such a case, you will
need a second sterile towel (later) to
cover your sterile field.
CAUTION: At all times, make sure that
you do not touch the sterile side of the
towel. Avoid letting the towel come in
contact with your uniform, other
objects, or contaminated areas.
6. Correctly unwrap the package contain-
ing the sterile basin. Place the basin on
the sterile field. Do not place it close to
the edge.
NOTE: A 2-inch border around the out-
side edges of the sterile field is consid-
FIGURE 14-38A Pick up the sterile towel at ered to be contaminated. No equipment
its outer edge and allow it to open by releasing should come in contact with this border.
the fanfolds. CAUTION: Make sure that the wrapper
does not touch the towel while placing
the basin in position.
7. Unwrap the package containing the
sterile cotton balls or gauze sponges.
Use a dropping motion to place them in
the basin. Do not touch the basin with
the wrapper.
8. Unwrap the package containing the
larger dressing. Use the sterile forceps
to remove the dressing from the pack-
age and place it on the sterile field. Make
sure the dressing is not too close to the
edge of the sterile field.
NOTE: The larger, outside dressing is
FIGURE 14-38B Place the towel on the Mayo placed on the sterile field first (before
stand without reaching across the top of the other dressings). In this way, the sup-
towel. plies will be in the order of use. For
PROCEDURE 14:8B
example, gauze dressings placed directly
on the skin will be on top of the pile, and
a thick abdominal pad used on top of
the gauze pads will be on the bottom of
the pile.
NOTE: The forceps must be lifted
straight up out of the container and
must not touch the side or rim of the
container. Keep the tips pointed down
and above the waist at all times. Shake
off excess disinfectant solution.
9. Unwrap the inner dressings correctly.
Use the sterile forceps to place them on
top of the other dressings on the sterile
field, or use a drop technique.
NOTE: Dressings are now in a pile; the FIGURE 14-39 Avoid splashing the solution
dressing that will be used first is on the onto the sterile field while pouring it into the
top of the pile. basin.
NOTE: The number and type of dress-

ings needed is determined by checking
NOTE: A second sterile towel may be
the patient being treated.
used to cover the supplies if the sterile
10. Open the bottle containing the correct field area is too large to be covered by
antiseptic solution. Place the cap on the the one fanfolded towel (figure 14-40).
table, with the inside of the cap facing CAUTION: Never reach across the top of
up. Pour a small amount of the solution the sterile tray.
into the sink to clean the lip of the bot-
tle. Then hold the bottle over the basin
and pour a sufficient amount of solu-
tion into the basin (figure 14-39).
CAUTION: Make sure that no part of the
bottle touches the basin or the sterile
field. Pour carefully to avoid splashing.
If the sterile field gets wet, the entire tray
will be contaminated, and you must
begin again.
11. Check the tray to make sure all needed
equipment is on it.
12. Pick up the fanfolded edge of the towel
by placing one hand on each side edge
of the towel on the underside, or con-
taminated side. Do not touch the sterile
side. Keep your hands and arms to the
side of the tray, and bring the towel for-
FIGURE 14-40 Use a second sterile towel to
cover the sterile towel to cover the sterile field,
ward to cover the supplies.
taking care not to reach across the field.
392 CHAPTER 14
PROCEDURE 14:8B
13. Once the sterile tray is ready, never allow
it out of your sight. Take it to the patient
area and use it immediately. If you need
more equipment, you must take the tray Practice
with you. This is the only way to be com- Go to the workbook and use the
pletely positive that the tray does not evaluation sheet for 14:8B,
become contaminated. Preparing a Sterile Dressing Tray, to
14. Replace equipment.
15. Wash hands. sign the sheet and give it to your

PROCEDURE 14:8C
CAUTION: If you touch the inside of the
Donning and package (where the gloves are), get a
Removing Sterile new package and start again.
Gloves 4. The glove for the right hand will be on
the right side and the glove for the left
Equipment and Supplies hand will be on the left side of the pack-
age. With the thumb and forefinger of
Sterile gloves the nondominant hand, pick up the top
edge of the folded-down cuff (inside of
Procedure glove) of the glove for the dominant
hand. Remove the glove carefully (figure
1. Assemble equipment and take it to the 14-41B).
area where it is to be used. Check the
package for stains, tears, moisture, or CAUTION: Do not touch the outside of
evidence of contamination. Do not use the glove. This is sterile. Only the part
the package if there is any evidence of that will be next to the skin can be
contamination. touched. Remember, unsterile touches
unsterile and sterile touches sterile.
2. Remove rings. Wash hands. Dry hands
thoroughly. 5. Hold the glove by the inside cuff and slip
the fingers and thumb of your other
3. Open the package of gloves, taking care hand into the glove. Pull it on carefully
not to touch the inside of the inner (figure 14-41C).
wrapper. The inner wrapper contains
the gloves. Reach in from the sides to NOTE: Hold the glove away from the
open the inner package and expose the body. Pull gently to avoid tearing the
sterile gloves (figure 14-41A). The folded glove.
cuffs will be nearest you.
PROCEDURE 14:8C
6. Insert your gloved hand under the cuff 8. Turn the cuffs up by manipulating only
(outside) of the other glove and lift the the sterile surface of the gloves (sterile
glove from the package (figure 14-41D). touches sterile). Go up under the folded
Do not touch any other area with your cuffs, pull out slightly, and turn cuffs
gloved hand while removing the glove over and up (figure 14-41F.) Do not
from the package. touch the inside of the gloves or the skin
with your gloved hand.
CAUTION: If contamination occurs, dis-
card the gloves and start again. 9. Interlace the fingers to position the
gloves correctly, taking care not to touch
7. Holding your gloved hand under the
the skin with the gloved hands (figure
cuff of the glove, insert your other hand
14-41G).
into the glove (figure 14-41E). Keep the
thumb of your gloved hand tucked in to CAUTION: If contamination occurs,
avoid possible contamination. start again with a new pair of gloves.
FIGURE 14-41A Reach in FIGURE 14-41B Pick up the FIGURE 14-41C Hold the
from the sides to open the inner first glove by grasping the glove glove securely by the cuff and
package and expose the sterile on the top edge of the folded- slip the opposite hand into the
gloves. down cuff. glove.
FIGURE 14-41D Slip the FIGURE 14-41E Hold the FIGURE 14-41F Insert the
gloved fingers under the cuff of gloved hand under the cuff gloved fingers under the cuff,
the second glove to lift it from while inserting the other hand pull out slightly, and turn the
the package. into the glove. cuffs over and up without
touching the inside of the
gloves or the skin.
394 CHAPTER 14
PROCEDURE 14:8C
ing performance of the procedure. Now
you must consider the outside of the
gloves contaminated, and the area
inside, next to your skin, clean.
13. Insert your bare fingers on the inside of
the second glove. Remove the glove by
pulling it down gently, taking care not to
touch the outside of the glove with your
bare fingers. It will be wrong side out
when removed.
FIGURE 14-41G Interlace the fingers to CAUTION: Avoid touching your uniform
position the gloves correctly, taking care not to or any other object with the contami-
touch the skin with the gloved hands. nated gloves.
10. Do not touch anything that is not sterile 14. Put the contaminated gloves in an infec-
once the gloves are in place. Gloves are tious waste container immediately after
applied for the purpose of performing removal.
procedures requiring sterile technique.
15. Wash your hands immediately and thor-
During the procedure, they will become
oughly after removing gloves.
contaminated with organisms related to
the patient’s condition, for example, 16. Once the gloves have been removed,
wound drainage, blood, or other body do not handle any contaminated
discharges. Even a clean, dry wound equipment or supplies such as soiled
may contaminate gloves. dressings or drainage basins. Protect
yourself.
NOTE: Gloved hands should remain in
position above the waist. Do not allow 17. Replace equipment if necessary.
them to fall below waist. 18. Wash hands thoroughly.
11. After the procedure requiring sterile
gloves is completed, dispose of all con-
taminated supplies before removing
gloves.
NOTE: This reduces the danger of
Practice
cross-infection caused by handling con-
evaluation sheet for 14:8C, Donning
taminated supplies without glove pro-
and Removing Sterile Gloves, to
tection.
12. To remove the gloves, use one gloved believe you have mastered this skill,
hand to grasp the other glove by the out- sign the sheet and give it to your
side of the cuff. Taking care not to touch instructor for further action.
the skin, remove the glove by pulling it
down over the hand. It will be wrong
side out when removed.
NOTE: This prevents contamination of listed on the evaluation sheet, your
your hands by organisms picked up dur- instructor will grade your performance.
PROCEDURE 14:8D
7. Screen the unit or draw curtains to pro-
Changing a Sterile vide privacy for the patient. If the patient
Dressing is in a bed, elevate the bed to a comfort-
able working height and lower the side-
Equipment and Supplies rail. Expose the body area needing the
dressing change. Use sheets or drapes
Sterile tray with basin, solution, gauze as necessary to prevent unnecessary
sponges and pads (or a prepared sterile dress- exposure of the patient.
ing package); sterile gloves; adhesive or non-
8. Fold down a 2- to 3-inch cuff on the top
allergic tape; disposable gloves; infectious
of the infectious waste bag. Position it in
waste bag
a convenient location. Tear off the tape
you will need later to secure the clean
Procedure dressing. Place it in an area where it will
be available for easy access.
1. Check doctor’s written orders or obtain
orders from immediate supervisor. 9. Put on disposable, nonsterile gloves.
Gently but firmly remove the tape from
NOTE: Dressings should not be changed
the soiled dressing. Discard it in the
without orders.
infectious waste bag. Hold the skin taut
NOTE: The policy of your agency will and then lift the dressing carefully, tak-
determine how you obtain orders for ing care not to pull on any surgical
procedures. drains. Note the type, color, and amount
2. Assemble equipment. Check autoclave of drainage on the dressing. Discard
indicator and date on all equipment. If dressing in the infectious waste bag.
more than 30 days have elapsed, use NOTE: Surgical drains are placed in
another package with a more recent some surgical incisions to aid in the
date. Put the unsterile package aside for removal of secretions. Care must be
resterilization. taken to avoid moving the drains when
3. Wash hands thoroughly. the dressing is removed.
4. Prepare a sterile tray as previously 10. Check the incision site. Observe the type
taught in Procedure 14:8B or obtain a and amount of remaining drainage, color
commercially prepared sterile dressing of drainage, and degree of healing.
package. CAUTION: Report any unusual obser-
NOTE: Prepared packages are used in vations immediately to your supervisor.
some agencies. Examples are bright red blood, pus,
swelling, or abnormal discharges at the
CAUTION: Never let the tray out of your wound site or patient complaints of
sight once it has been prepared. pain or dizziness.
5. Take all necessary equipment to the 11. Remove disposable gloves and place in
patient area. Place it where it will be infectious waste bag. Immediately wash
convenient for use yet free from possi- your hands.
ble contamination by other equipment.
CAUTION: Nonsterile disposable gloves
6. Introduce yourself. Identify the patient. should be worn while removing dress-
Explain the procedure. Close the door ings to avoid contamination of the
and/or windows to avoid drafts and flow hands or skin by blood or body dis-
of organisms into the room. charge.
396 CHAPTER 14
PROCEDURE 14:8D
12. Fanfold the top cover back to uncover 16. Do not cleanse directly over the wound
the sterile field. unless there is a great deal of drainage
or it is specifically ordered by the physi-
CAUTION: Handle only the contami-
cian. If this is to be done, use sterile
nated (outside) side of the towel. The
gauze and wipe with a single stroke from
side in contact with the tray’s contents
the top to the bottom. Discard the soiled
is the sterile side.
gauze. Repeat as necessary, using a new
NOTE: If a prepared package is used, sterile gauze sponge each time.
open it at this time.
17. The wound is now ready for clean dress-
13. Don sterile gloves as previously taught ings. Lift the sterile dressings from the
in Procedure 14:8C. tray and place them lightly on the
14. Using thumb and forefinger, pick up a wound. Make sure they are centered
gauze sponge from the basin. Squeeze it over the wound.
slightly to remove any excess solution. NOTE: The inner dressing is usually
Warn the patient that the solution may made up of 4-by-4-inch gauze sponges.
be cool.
18. Apply outer dressings until the wound is
15. Cleanse the wound. Use a circular sufficiently protected.
motion (figure 14-42).
NOTE: Heavier dressings such as
NOTE: Begin near the center of the abdominal pads are usually used.
wound and move outward or away from
NOTE: The number and size of dress-
the wound. Make an ever-widening cir-
ings needed to dress the wound will
cle. Discard the wet gauze sponge after
depend on the amount of drainage and
use. Never go back over the same area
the size of the wound.
with the same gauze sponge. Repeat this
procedure until the area is clean, using a 19. Remove the sterile gloves as previously
new gauze sponge each time. taught. Discard them in the infectious
waste bag. Immediately wash your
hands.
20. Place the precut tape over the dressing
at the proper angle. Check to make sure
that the dressing is secure and the ends
are closed.
NOTE: Tape should be applied so it runs
opposite from body action or move-
ment (figure 14-43). It should be the
correct width for the dressing. It should
Start in be long enough to support the dressing,
center
but it should not be too long because it
will irritate the patient’s skin.
21. Check to be sure the patient is comfort-
End able and that safety precautions have
been observed before leaving the area.
FIGURE 14-42 Use a circular motion to clean
the wound, starting at the center of the wound 22. Put on disposable, nonsterile gloves.
and moving in an outward direction. Clean and replace all equipment used.
PROCEDURE 14:8D
of drainage, and any other pertinent
information, or tell this information to
your immediate supervisor.
Example: 1/8/—, 9:00 A.M. Dressing
changed on right abdominal area. Small
amount of thick, light-yellow discharge
noted on dressings. No swelling or
inflammation apparent at incision site.
Sterile dressing applied. Your signature
and title.
NOTE: Report any unusual observations
immediately.
FIGURE 14-43 Tape should be applied
so that it runs opposite to body action or
movement.
Tie or tape the infectious waste bag
securely. Dispose of it according to
agency policy.
Practice
CAUTION: Disposable, nonsterile gloves evaluation sheet for 14:8D,
should be worn to provide a protective Changing a Sterile Dressing, to
barrier while cleaning equipment or practice this procedure. When you
supplies that may be contaminated by believe you have mastered this skill,
blood or body fluids. sign the sheet and give it to your
23. Remove disposable gloves. Wash hands instructor for further action.
thoroughly. Protect yourself from possi-
ble contamination.
24. Record the following information on the Final Checkpoint Using the criteria
patient’s chart or agency form: date, listed on the evaluation sheet, your
time, dressing change, amount and type instructor will grade your performance.
14:9 INFORMATION ple at the same time. A pandemic exists when

the outbreak of disease occurs over a wide geo-
Maintaining Transmission-Based graphic area and affects a high proportion of the
Isolation Precautions population. Because individuals can travel read-
ily throughout the world, a major concern is that
INTRODUCTION worldwide pandemics will become more and
more frequent.
In health occupations, you will deal with Transmission-based isolation precau-
many different diseases/disorders. Some tions are a method or technique of caring
diseases are communicable and require isola- for patients who have communicable diseases.
tion. A communicable disease is caused by a Examples of communicable diseases are tuber-
pathogenic organism that can be easily transmit- culosis, wound infections, and pertussis (whoop-
ted to others. An epidemic occurs when the ing cough). Standard precautions, discussed in
communicable disease spreads rapidly from per- Information section 14:4, do not eliminate the
son to person and affects a large number of peo- need for specific transmission-based isolation
398 CHAPTER 14
precautions. Standard precautions are used on Two terms are extensively used in transmis-
all patients. Transmission-based isolation tech- sion-based isolation: contaminated and clean.
niques are used to provide extra protection These words refer to the presence of organisms
against specific diseases or pathogens to prevent on objects.
their spread.
♦ Contaminated, or dirty, means that objects
Communicable diseases are spread in many
contain disease-producing organisms. These
ways. Some examples include direct contact with
objects must not be touched, unless the health
the patient; contact with dirty linen, equipment,
worker is protected by gloves, gown, and other
and/or supplies; and contact with blood, body
required items.
fluids, secretions, and excretions such as urine,
feces, droplets (from sneezing, coughing, or spit- NOTE: The outside and waist ties of the gown,
ting), and discharges from wounds. Transmission- protective gloves, and mask are considered
based isolation precautions are used to limit contaminated.
contact with pathogenic organisms. These tech- ♦ Clean means that objects or parts of objects
niques help prevent the spread of the disease to do not contain disease-producing organisms
other people and protect patients, their families, and therefore have minimal chance of spread-
and health care providers. ing the disease. Every effort must be made to
The type of transmission-based isolation prevent contamination of these objects or
used depends on the causative organism of the parts of objects.
disease, the way the organism is transmitted, and NOTE: The insides of the gloves and gown are
whether the pathogen is antibiotic resistant (not clean, as are the neckband, its ties, and the
affected by antibiotics). Personal protective mask ties.
equipment (PPE) is used to provide protection
from the pathogen. Some transmission-based The Centers for Disease Control and Preven-
isolation precautions require the use of gowns, tion (CDC) in conjunction with the National
gloves, face shields, and masks (figure 14-44), Center for Infectious Diseases (NCID) and the
while others only require the use of a mask. Hospital Infection Control Practices Advisory
Committee (HICPAC) has recommended four
main classifications of precautions that must be
followed: standard, airborne, droplet, and con-
tact. Health care facilities are provided with a list
of infections/conditions that shows the type and
duration of precautions needed for each specific
disease. In this way, facilities can follow the guide-
lines to determine the type of transmission-based
isolation that should be used along with the spe-
cific precautions that must be followed.
STANDARD
PRECAUTIONS
Standard precautions (discussed in Information
section 14:4) are used on all patients. In addition,
a patient must be placed in a private room if the
patient contaminates the environment or does
not (or cannot be expected to) assist in maintain-
ing appropriate hygiene. Every health care worker
FIGURE 14-44 Some transmission-based must be well informed about standard precau-
isolation precautions require the use of gowns, tions and follow the recommendations for the
gloves, and a mask, while others only require the use of gloves, gowns, and face masks when con-
use of a mask. ditions indicate their use.
a high-efficiency particulate air (HEPA) mask

AIRBORNE (figures 14-46A, B). These masks contain spe-
PRECAUTIONS cial filters to prevent the entrance of the small
airborne pathogens. The masks must be fit
Airborne precautions (figure 14-45) are used tested to make sure they create a tight seal
for patients known or suspected to be infected each time they are worn by a health care pro-
with pathogens transmitted by airborne droplet vider. Men with facial hair cannot wear a stan-
nuclei. These are small particles of evaporated dard filtering mask because a beard prevents
droplets that contain microorganisms and remain an airtight seal. Men with facial hair can use a
suspended in the air or on dust particles. Exam- special HEPA-filtered hood.
ples of diseases requiring these isolation precau- ♦ People susceptible to measles or chicken pox
tions are rubella (measles), varicella (chicken should not enter the room.
pox), tuberculosis, and shingles or herpes zoster
♦ If at all possible, the patient should not be
(varicella zoster). Standard precautions are used
moved from the room. If transport is essential,
at all times. In addition, the following precautions
however, the patient must wear a surgical
must be taken:
mask during transport to minimize the release
♦ The patient must be placed in a private room, of droplets into the air.
and the door should be kept closed.
♦ Air in the room must be discharged to outdoor
air or filtered before being circulated to other DROPLET PRECAUTIONS
areas. Droplet precautions (figure 14-47) must be fol-
♦ Each person who enters the room must wear lowed for a patient known or suspected to be
respiratory protection in the form of an N95, infected with pathogens transmitted by large-
P100 or more powerful filtering mask such as particle droplets expelled during coughing, sneez-
AIRBORNE PRECAUTIONS
In Addition to Standard Precautions
Visitors - Report to Nurses' Station Before Entering Room
BEFORE CARE DURING CARE AFTER CARE
1. Private room and closed 1. Limit transport of patient/resident 1. Bag linen to
door with monitored to essential purposes prevent contamination
negative air pressure, only. Patient resident of self, environment, or
frequent air exchanges, must wear mask outside of bag.
and high-efficiency filtration. appropriate for
disease.
2. Wash hands.
2. Discard infectious trash
to prevent contamination
of self, environment, or
2. Limit use of outside of bag.
noncritical care
equipment to
3. Wear respiratory protection a single
appropriate for disease. patient/resident.
3. Wash hands.
FIGURE 14-45 Airborne precautions. (Courtesy of Brevis Corporation)

400 CHAPTER 14
FIGURE 14-46A The N95 respirator mask.

(Courtesy of 3M Company, St. Paul, MN)
FIGURE 14-46B The P100 respirator mask.
(Courtesy of 3M Company, St. Paul, MN)
ing, talking, or laughing. Examples of diseases pneumonia, sinusitis, and otitis media; diphthe-
requiring these isolation precautions include ria; Mycoplasma pneumonia; pertussis; adenovi-
Haemophilus influenzae meningitis and pneu- rus; mumps; and severe viral influenza. Standard
monia; Neisseria meningitis and pneumonia; precautions are used at all times. In addition, the
multidrug-resistant Streptococcus meningitis, following precautions must be taken:
DROPLET PRECAUTIONS
1. Private room. 1. Limit transport of patient/resident 1. Bag linen to
Maintain 3 feet of to essential purposes prevent contamination
spacing between only. Patient/resident of self, environment, or
patient/resident must wear mask outside of bag.
and visitors. appropriate for
disease.

2. Mask/face shield for staff 2. Limit use of outside of bag.
and visitors within 3 feet noncritical care
of patient/resident. equipment to
a single 3. Wash hands.
patient/resident.
FIGURE 14-47 Droplet precautions. (Courtesy of Brevis Corporation)

♦ The patient should be placed in a private enterohemorrhagic E. coli, Shigella, hepatitis A,

room. If a private room is not available and or rotavirus; viral or hemorrhagic conjunctivitis
the patient cannot be placed in a room with a or fevers; and any skin infections that are highly
patient who has the same infection, a distance contagious or that may occur on dry skin, such as
of at least 3 feet should separate the infected diphtheria, herpes simplex virus, impetigo,
patient and other patients or visitors. pediculosis (head or body lice), scabies, and
staphylococcal infections. Standard precautions
♦ Masks must be worn when working within 3 are used at all times. In addition, the following
feet of the patient, and the use of masks any-
precautions must be taken:
where in the room is strongly recommended
♦ The patient should be placed in a private
♦ If transport or movement of the patient is room or, if a private room is not available, in a
essential, the patient must wear a surgical
room with a patient who has an active infec-
mask.
tion caused by the same organism.
♦ Gloves must be worn when entering the
CONTACT PRECAUTIONS room.
♦ Gloves must be changed after having contact
Contact precautions (figure 14-48) must be with any material that may contain high con-
followed for any patients known or suspected to centrations of the microorganism, such as
be infected with epidemiologically (capable of wound drainage or fecal material.
spreading rapidly from person to person, an epi-
demic) microorganisms that can be transmitted ♦ Gloves must be removed before leaving the
by either direct or indirect contact. Examples of room, and the hands must be washed with an
diseases requiring these precautions include any antimicrobial agent.
gastrointestinal, respiratory, skin, or wound ♦ A gown must be worn in the room if there is any
infections caused by multidrug-resistant organ- chance of contact with the patient, environ-
isms; diapered or incontinent patients with mental surfaces, or items in the room. The
CONTACT PRECAUTIONS
1. Private room. 1. Limit transport of patient/resident 1. Bag linen to
to essential purposes prevent contamination
only. Patient/resident of self, environment, or
must wear mask outside of bag.
appropriate for
2. Wash hands. disease.
3. Wear gown if soiling is likely. 2. Limit use of outside of bag.
noncritical care
equipment to
a single
patient/resident. 3. Wash hands.
4. Wear gloves when
entering room.
Change after contact
with infective material.
FIGURE 14-48 Contact precautions. (Courtesy of Brevis Corporation)

402 CHAPTER 14
gown must be removed before leaving the room ♦ Frequent disinfection occurs while the patient
and care must be taken to ensure that clothing occupies the room
is not contaminated after gown removal.
♦ Anyone entering the room must wear clean or
♦ Movement and transport of the patient from sterile gowns, gloves, and masks
the room should be for essential purposes
only.
♦ All equipment or supplies brought into the
room are clean, disinfected, and/or sterile
♦ The room and items in it must receive daily
cleaning and disinfection as needed.
♦ Special filters may be used to purify air that
enters the room
♦ If possible, patient-care equipment (bedside
commode, stethoscope, sphygmomanometer,
♦ Every effort is made to protect the patient
from microorganisms that cause infection or
thermometer) should be left in the room and
disease
used only for this patient. If this is not possi-
ble, all equipment must be cleaned and disin-
fected before being used on another patient.
SUMMARY
Exact procedures for maintaining transmission-
PROTECTIVE OR based isolation precautions vary from one facility
REVERSE ISOLATION to another. The procedures used depend on the
type of units provided for isolation patients, and
Protective or reverse isolation refers to meth- on the kind of supplies or special isolation equip-
ods used to protect certain patients from organ- ment available. Most facilities convert a regular
isms present in the environment. Protective patient room into an isolation room, but some
isolation is used mainly for immunocompromised facilities use special, two-room isolation units.
patients, or those whose body defenses are not Most facilities use disposable supplies such as
capable of protecting them from infections and gloves, gowns, and treatment packages. There-
disease. Examples of patients requiring this pro- fore, it is essential that you learn the isolation
tection are patients whose immune systems have procedure followed by your agency. However, the
been depressed prior to receiving transplants basic principles for maintaining transmission-
(such as bone marrow transplants), severely based isolation are the same regardless of the
burned patients, patients receiving chemother- facility. Therefore, if you know these basic prin-
apy or radiation treatments for cancer, or patients ciples, you will be able to adjust to any setting.
whose immune systems have failed. Precautions
vary depending on the patient’s condition. Stan-
dard precautions are used at all times. In addi-
tion, the following precautions may be taken:
the assignment sheet for 14:9, Maintaining
♦ The patient is usually placed in a room that Transmission-Based Isolation Precautions. Then
has been cleaned and disinfected return and continue with the procedures.
PROCEDURE 14:9A
transmission-based isolation, follow
Donning and only the steps that apply.
Removing
Transmission-Based Equipment and Supplies
Isolation Garments Isolation gown, surgical mask, gloves, small
NOTE: The following procedure deals plastic bag, linen cart or container, infectious
with contact transmission-based isola- waste container, paper towels, sink with run-
tion precautions. For other types of ning water
PROCEDURE 14:9A
Procedure NOTE: The tie bands on the mask are
considered clean. The mask is consid-
1. Assemble equipment. ered contaminated.
NOTE: In many agencies, clean isola- NOTE: The mask is considered to be
tion garments and supplies are kept contaminated after 30 minutes in isola-
available on a cart outside the isolation tion or anytime it gets wet. If you remain
unit, or in the outer room of a two-room in isolation longer than 30 minutes, or if
unit. A waste container should be posi- the mask gets wet, you must wash your
tioned just inside the door. hands, and remove and discard the old
mask. Then wash your hands again, and
2. Wash hands. put on a clean mask.
3. Remove rings and place them in your 6. If uniform sleeves are long, roll them up
pocket or pin them to your uniform. above the elbows before putting on the
4. Remove your watch and place it in a gown.
small plastic bag or centered on a clean 7. Lift the gown by placing your hands
paper towel. If placed on a towel, handle inside the shoulders.
only the bottom part of the towel; do not
touch the top. NOTE: The inside of the gown and the
ties at the neck are considered clean.
NOTE: The watch will be taken into the
room and placed on the bedside stand NOTE: Most agencies use disposable
for taking vital signs. Because it cannot gowns that are discarded after use.
be sterilized, it must be kept clean. 8. Work your arms into the sleeves of the
NOTE: In some agencies, a plastic-cov- gown by gently twisting (figure 14-49B).
ered watch is left in the isolation room. Take care not to touch your face with
the sleeves of the gown.
5. Put on the mask. Secure it under your
chin. Make sure to cover your mouth 9. Place your hands inside the neckband,
and nose. Handle the mask as little as adjust until it is in position, and then tie
possible. Tie the mask the bands at the back of your
securely behind your head neck (figure 14-49C).
and neck. Tie the top ties
first and the bottom ties
second (figure 14-49A).
FIGURE 14-49B After tying

the mask in place, put on the
FIGURE 14-49A Put on the gown by placing your hands FIGURE 14-49C Slip your
mask, tying the top ties before inside the shoulders to ease fingers inside the neckband to
the bottom ties. your arms into the sleeves. tie the gown at the neck.
404 CHAPTER 14
PROCEDURE 14:9A
10. Reach behind and fold the edges of the NOTE: The waist ties are considered
gown over so that the uniform is com- contaminated.
pletely covered. Tie the waistbands (fig-
15. If gloves are worn, remove the first glove
ure 14-49D). Some waistbands are long
by grasping the outside of the cuff with
enough to wrap around your body
the opposite gloved hand. Pull the glove
before tying.
over the hand so that the glove is inside
11. If gloves are to be worn, put them on. out (figure 14-50B). Remove the second
Make sure that the cuff of the glove glove by placing the bare hand inside
comes over the top of the cuff of the the cuff. Pull the glove off so it is inside
gown (figure 14-49E). In this way, there out. Place the disposable gloves in the
are no open areas for entrance of organ- infectious waste container.
isms.
16. To avoid unnecessary transmission of
12. You are now ready to enter the isolation organisms, use paper towels to turn on
room. Double-check to be sure you have the water faucet. Wash and dry your
all equipment and supplies that you will hands thoroughly. When they are dry,
need for patient care before you enter use a clean, dry paper towel to turn off
the room. the faucet.
13. When patient care is complete, you will CAUTION: Organisms travel rapidly
be ready to remove isolation garments. through wet towels.
In a two-room isolation unit, go to the
17. Untie the bottom ties of the mask first
outer room. In a one-room unit, remove
followed by the top ties. Holding the
garments while you are standing close
mask by the top ties only, drop it into
to the inside of the door. Take care to
the infectious waste container (figure
avoid touching the room’s contami-
14-50C).
nated articles.
NOTE: The ties of the mask are consid-
14. Untie the waist ties (figure 14-50A).
ered clean. Do not touch any other part
Loosen the gown at the waist.
of the mask, because it is considered
contaminated.
FIGURE 14-49D Overlap the back edges of FIGURE 14-49E Put on gloves making sure
the gown so your uniform is completely covered that the cuff of the glove is over the top of the
before tying the waist ties. cuff on the gown.
PROCEDURE 14:9A
18. Untie the neck ties. Loosen the gown at 22. With your hands inside the gown at the
the shoulders, handling only the inside shoulders, bring the shoulders together
of the gown. and turn the gown so that it is inside out
(figure 14-50F). In this manner, the out-
NOTE: The neck ties are considered
side of the contaminated gown is on the
clean.
inside. Fold the gown in half and then
19. Slip the fingers of one hand inside the roll it together. Place it in the infectious
opposite cuff. Do not touch the outside. waste container.
Pull the sleeve down over the hand (fig-
NOTE: Avoid excess motion during this
ure 14-50D).
procedure because motion causes the
CAUTION: The outside of the gown is spread of organisms.
considered contaminated and should
23. Wash hands thoroughly. Use dry, clean
not be touched.
paper towels to operate the faucets.
20. Using the gown-covered hand, pull the
24. Touch only the inside of the plastic bag
sleeve down over the opposite hand
to remove your watch. Discard the bag
(figure 14-50E).
in the waste container. If the watch is on
21. Ease your arms and hands out of the a paper towel, handle only the “clean,”
gown. Keep the gown in front of your top portion (if necessary). Discard the
body and keep your hands away from towel in the infectious waste container.
the outside of the gown. Use as gentle a
25. Use a clean paper towel to open the
motion as possible.
door. Discard the towel in the waste
NOTE: Excessive flapping of the gown container before leaving the room.
will spread organisms.
CAUTION: The inside of the door is con-
sidered contaminated.
FIGURE 14-50A Untie the

waist ties of the gown before
removing the gloves.
FIGURE 14-50B To remove FIGURE 14-50C Remove the

the gloves, pull them over the mask and hold only the top ties
hand so the glove is inside out. to drop it in an infectious waste
container.
406 CHAPTER 14
PROCEDURE 14:9A
FIGURE 14-50D To remove FIGURE 14-50E Using the FIGURE 14-50F With your
the gown, slip the fingers of one gown-covered hand, grasp the hands inside the gown at the
hand under the cuff of the outside of the gown on the shoulders, bring the shoulders
opposite arm to pull the gown opposite arm and pull the gown together and turn the gown so
down over the opposite hand. down over the hand. that it is inside out, with the
contaminated side on the inside.
NOTE: The waste container should be
positioned just inside the door of the
room.
26. After leaving the isolation room, wash
Practice
hands thoroughly. This will help prevent evaluation sheet for 14:9A, Donning
spread of the disease. It also protects and Removing Transmission-Based
you from the illness. Isolation Garments, to practice this
Final Checkpoint Using the criteria have mastered this skill, sign the
listed on the evaluation sheet, your sheet and give it to your instructor
instructor will grade your performance. for further action.
PROCEDURE 14:9B
Working in a Hospital Procedure
Transmission-Based 1. Assemble all equipment.
Isolation Unit NOTE: Any equipment or supplies to be
used in the isolation room must be
Equipment and Supplies assembled prior to entering the room.
2. Wash hands.
Clothes hamper, two laundry bags, two trays,
dishes, cups, bowls, waste container lined 3. Put on appropriate isolation garments
with a plastic bag, infectious waste bags, bags, as previously instructed.
tape, pencil, pen, paper
PROCEDURE 14:9B
4. Tape paper to the outside of the isola-
tion door. This will be used to record
vital signs.
5. Enter the isolation room. Take all needed
equipment into the room.
6. Introduce yourself. Greet and identify
patient. Provide patient care as needed.
NOTE: All care is provided in a routine
manner. However, transmission-based
isolation garments must be worn as
ordered.
7. To record vital signs:
a. Take vital signs using the watch in the
plastic bag. (If the watch is not in a
plastic bag, hold it with the bottom
part of a paper towel.) Use other
equipment in the room as needed.
b. Open the door touching only the
FIGURE 14-51 To transfer food into an
isolation unit, a health care worker holds the
inside, or contaminated side.
tray so the worker in isolation can transfer the
c. Using a pencil, record the vital signs food onto the tray kept inside the unit.
on the paper taped to the door. Do
not touch the outside of the door at e. Glasses should be held near the top
any time. by the transfer person on the outside.
NOTE: The pencil remains in the room The transfer person on the inside
because it is contaminated. should receive the glasses by holding
them on the bottom.
8. To transfer food into the isolation unit:
9. To dispose of leftover food or waste:
a. Transfer of food requires two people;
one person must stay outside the unit a. Liquids can be poured down the sink
and one inside. or flushed down the toilet.
b. The person inside the isolation unit b. Soft foods such as mashed potatoes
picks up the empty tray in the room or cooked vegetables can be flushed
and opens door, touching only the down the toilet.
inside of the door. c. Hard particles of food, such as bone,
c. The person outside holds the tray should be placed in the plastic-lined
while the dishes are being transferred trash container.
(figure 14-51). d. Disposable utensils or dishes should
d. When transferring food, the two be placed in the plastic-lined trash
people should handle the opposite container.
sides of the dishes. In this manner, e. Metal utensils should be washed and
one person will not touch the other kept in the isolation room to be used
person. as needed for other meals. These
408 CHAPTER 14
PROCEDURE 14:9B
utensils, however, are contaminated. c. Tie a knot at the top of the bag to seal
When they are removed from the iso- it or fold the top edge twice and tape
lation room, they must be disinfected it securely.
or double bagged and labeled before
d. Place this bag inside a cuffed biohaz-
being sent for decontamination and
ardous waste bag held by a “clean”
reprocessing.
person outside the unit (figure 14-
10. To transfer soiled linen from the unit, 52).
two people are required:
e. The outside person then ties the
a. All dirty linen should be folded and outer bag securely or tapes the outer
rolled. bag shut.
b. Place linen in the linen hamper. f. The double-bagged trash should then
be burned. Double-bagged infectious
c. The person outside the unit should
waste is autoclaved prior to incinera-
cuff the top of a clean infectious
tion or disposal as infectious waste
waste laundry bag and hold it. Hands
according to legal requirements.
should be kept on the inside of the
bag’s cuff to avoid contamination. g. At all times, direct contact between
the two people transferring trash
d. The person in isolation should seal
must be avoided.
the isolation bag. The bag is then
placed inside the outer bag, which is 12. To transfer equipment from the isola-
being held by the person outside. tion unit two people are required:
e. Outer bag should be folded over at
the top and taped by the person out-
side. The bag should be labeled as
“BIOHAZARDOUS LINEN.”
f. At all times, no direct contact should
occur between the two people trans-
ferring linen.
NOTE: Many agencies use special isola-
tion linen bags. Hot water dissolves the
bags during the washing process. There-
fore, no other personnel handle the
contaminated linen after it leaves the
isolation unit.
11. To transfer trash from the isolation unit,
two people are required:
a. Any trash in the isolation room
should be in plastic bags. Any trash
or disposable items contaminated
with blood, body fluids, secretions,
or excretions should be placed in FIGURE 14-52 To transfer infectious waste
from an isolation unit, the worker in the unit
infectious waste bags.
places the sealed infectious waste bag inside a
b. When the bag is full, expel excess air second bag held by a “clean” worker outside the
by pushing gently on the bag. unit.
PROCEDURE 14:9B
a. Thoroughly clean and disinfect all transferred out of the unit using the
equipment in the unit. appropriate isolation technique.
b. After cleaning, place equipment in a 14. Before leaving an isolation room, ask
plastic bag or special isolation bag. the patient whether a urinal or bedpan
Label the bag with the contents and is needed. This will save time and energy
the word “ISOLATION.” by reducing the need to return to pro-
vide additional patient care shortly after
c. After folding the bag down twice at
leaving. Also, prior to leaving, check all
the top, tape the bag shut.
safety and comfort points to make sure
d. A second person outside the isola- patient care is complete.
tion room should hold a second,
15. Remove isolation garments as previ-
cuffed infectious waste bag.
ously instructed in Procedure 14:9A.
e. The person in isolation places the
16. Wash hands thoroughly.
sealed, contaminated bag inside the
bag being held outside the unit. The
person in isolation should have no
direct contact with the clean bag.
f. The person outside the unit turns Practice
down the top of the infectious waste Go to the workbook and use the
bag twice and securely tapes the bag. evaluation sheet for 14:9B, Working
The outside person then labels the in a Hospital Transmission-Based
bag with the contents, for example, Isolation Unit, to practice this
“ISOLATION DISHES.” procedure. When you believe you
g. The double-bagged material is then have mastered this skill, sign the
sent to Central Supply or another sheet and give it to your instructor
designated area for sterilization and/ for further action.
or decontamination.
13. The transmission-based isolation unit Final Checkpoint Using the criteria
must be kept clean and neat at all times. listed on the evaluation sheet, your
Equipment no longer needed should be instructor will grade your performance.
CHAPTER 14 SUMMARY that could be used for bioterrorism. In today’s

world, it is likely that an attack will occur. Every
health care worker must constantly be alert to
Understanding the basic principles of infection the threat of bioterrorism. Careful preparation
control is essential for any health care worker in of a comprehensive plan against bioterrorism
any health care field. Disease is caused by a wide and thorough training of all individuals can
variety of pathogens, or germs. An understand- limit the effect of the attack and save the lives of
ing of the types of pathogens, methods of trans- many people.
mission, and the chain of infection allows health Asepsis is defined as “the absence of disease-
care workers to take precautions to prevent the producing microorganisms, or pathogens.” Vari-
spread of disease. ous levels of aseptic control are possible. Anti-
Bioterrorism is the use of microorganisms as sepsis refers to methods that prevent or inhibit
weapons to infect humans, animals, or plants. the growth of pathogenic organisms. Proper
The CDC has identified and classified agents handwashing and using an ultrasonic unit to
410 CHAPTER 14

Super water that kills germs?
Treating chronic wounds is a multibillion-dollar market worldwide. Any health product
catalog advertises hundreds of antiseptics and disinfectants designed to kill germs. How-
ever, many of these products irritate the skin, and only a few can be used on open infected
sores.
Now scientists have created a superoxygenated water, Microcyn, that appears to kill bac-
teria, viruses, fungi, mold, and spores. Microcyn is water mixed with salt that has been charged
with an electric current to create superoxidized water. The highly oxidized water contains
hydrogen ions that have been split. The ions surround and rupture the cell wall of a single-
cell organism, such as a bacterium or virus, and cause the organism to lose its cytoplasm,
effectively killing the cell. Multicellular organisms, such as humans, are not affected by the
ions because their cells are packed closely together, forming an effective wall to prevent the
superoxygenated water from surrounding the cells. Early tests show that chronic diabetic
ulcers and burns heal quickly when this solution is used in place of other antiseptics.
In the United States, approximately 18.2 million people, or 6.3 percent of the population,
have diabetes. As the disease progresses, many of these individuals experience develop-
ment of chronic ulcers that do not heal. Statistics show that more than 60 percent of non-
traumatic lower leg amputations occur in people with diabetes. Many amputations could be
avoided if chronic ulcers could be healed. In addition, think of the many other uses for this
superwater. It could be used as an effective handwashing agent. It could be used as a spray
mist to disinfect a room. It might even prove to be an agent that can be used to stop a flu
epidemic or a biologic terrorist attack. If this superwater can destroy many of the germs that
cause disease, it will change health care.
clean instruments and supplies are examples. the recommended standard precautions while
Disinfection is a process that destroys or kills working with all patients.
pathogenic organisms, but is not always effec- Sterile techniques are used in specific pro-
tive against spores and viruses. Chemical disin- cedures, such as changing dressings. Health
fectants are used for this purpose. Sterilization care workers must learn and follow sterile tech-
is a process that destroys all microorganisms, niques when they are required to perform these
including spores and viruses. The use of an au- procedures.
toclave is an example. Instruments and equip- Transmission-based isolation precautions
ment are properly prepared, and then processed are used for patients who have communicable
in the autoclave to achieve sterilization. diseases, or diseases that are easily transmitted
Following the standard precautions estab- from one person to another. An awareness of
lished by the CDC helps prevent the spread of the major types of transmission-based isolation
pathogens by way of blood, body fluids, secre- presented in this unit will help the health care
tions, and excretions. The standard precautions worker prevent the transmission of communi-
provide guidelines for handwashing; wearing cable diseases.
gloves; using gowns, masks, and protective eye- Infection control must be followed when
wear when splashing is likely; proper handling performing any and every health care proce-
and disposal of contaminated sharp objects; dure. By learning and following the principles
proper disposal of contaminated waste; and discussed in this unit, health care workers will
proper methods to wipe up spills of blood, body protect themselves, patients, and others from
fluids, secretions, and excretions. Every health disease.
care worker must be familiar with and follow
and Prevention Act, Standard Precautions, and

INTERNET SEARCHES Transmission-Based Isolation Precautions
(airborne precautions, droplet precautions,
Use the suggested search engines in Chapter 12:4 and contact precautions)
tional information on the following topics: 8. Medical supply companies: search for names of
specific medical supply companies to research
1. Organizations regulating infection control: find products available such as autoclaves, chemi-
the organization sites for the Occupational cal disinfectants, and spill clean-up kits
Safety and Health Administration (OSHA),
Centers for Disease Control and Prevention
(CDC), National Center for Infectious Diseases REVIEW QUESTIONS
(NCID), and the Hospital Infection Control
Practices Advisory Committee (HICPAC) to
1. List the classifications of bacteria by shape and
obtain information on regulations governing
give two (2) examples of diseases caused by
infection control
each class.
2. Microbiology: search for specific information
2. Draw the chain of infection and identify three
on bacteria (can also search for specific types
(3) ways to break each section of the chain.
such as Escherichia coli), protozoa, fungi,
rickettsiae, and viruses 3. Differentiate between antisepsis, disinfection,
and sterilization.
3. Diseases: obtain information on the method of
transmission, signs and symptoms, treatment, 4. Develop a plan showing at least five (5) ways
and complications for diseases such as hepati- you can protect yourself and your family from
tis B, hepatitis C, acquired immune deficiency a bioterrorism attack.
syndrome, and specific diseases listed by the
5. List eight (8) times the hands must be washed.
discussion on microorganisms in this unit
6. Name the different types of personal protective
4. Infections: research endogenous infections,
equipment (PPE) and state when each type
exogenous infections, nosocomial infections,
must be worn to meet the requirements of
and opportunistic infections
standard precautions.
5. Bioterrorism: find information on pathogens
7. What level of infection control is achieved by
that can be used as weapons, how they are
an ultrasonic cleaner? chemicals? an auto-
spread, methods for prevention and/or treat-
clave?
ment of diseases caused by the pathogens, and
bioterrorism preparedness plans developed as 8. Name three (3) methods that can be used to
a result of the Bioterrorism Act of 2002 place sterile items on a sterile field. Identify the
types of items that can be transferred by each
6. Foreign trip: plan a trip to an exotic foreign
method.
country; research the Internet to determine
specific health precautions that must be taken 9. List the three (3) types of transmission-based
during your stay, and determine which immu- isolation precautions and the basic principles
nizations you will need before the trip that must be followed for each type.
7. Infection control: locate and read the Blood-
borne Pathogen Standards, Needlestick Safety
CHAPTER 15 Vital Signs
Chapter Objectives
Observe Standard ◆ List the four main vital signs
Precautions ◆ Convert Fahrenheit to Celsius, or vice versa
◆ Read a clinical thermometer to the nearest
two-tenths of a degree
Instructor at This Point ◆ Measure and record oral temperature
accurately
◆ Measure and record rectal temperature
Safety—Proceed with accurately
Caution ◆ Measure and record axillary temperature
accurately
◆ Measure and record tympanic (aural)
on Federal Law temperature accurately
◆ Measure and record temporal temperature
accurately
Math Skill ◆ Measure and record radial pulse to an accuracy
within ± 2 beats per minute
◆ Count and record respirations to an accuracy
within ± 1 respiration per minute
◆ Measure and record apical pulse to an
Science Skill accuracy within ± 2 beats per minute
◆ Measure and record blood pressure to an
accuracy within ± 2 mm of actual reading
Career Information ◆ State the normal range for oral, axillary, and
rectal temperature; pulse; respirations; and
systolic and diastolic pressure
Technology
Vital Signs 413
KEY TERMS
apical pulse (ape-ih-kal) homeostasis respirations
apnea (ap-nee-ah) (home-ee-oh-stay-sis) rhythm
arrhythmia (ah-rith-me-ah) hypertension sphygmomanometer (sfig-
aural temperature hyperthermia moh-ma-nam-eh-ter)
axillary temperature (high-pur-therm-ee-ah) stethoscope (steth-uh-scope)
blood pressure hypotension systolic (sis-tall-ik)
bradycardia hypothermia tachycardia
(bray-dee-car-dee-ah) (high-po-therm-ee-ah) (tack-eh-car-dee-ah)
bradypnea (brad-ip-nee-ah) oral temperature tachypnea (tack-ip-nee’-ah)
character orthopnea (or-thop-nee-ah) temperature
Cheyne–Stokes pulse temporal scanning
(chain stokes) pulse deficit thermometer
clinical thermometers pulse pressure temporal temperature
cyanosis pyrexia tympanic thermometers
diastolic (die-ah-stall-ik) rale (rawl) vital signs
dyspnea (dis(p)-nee-ah) rate volume
electronic thermometers rectal temperature wheezing
fever
15:1 INFORMATION information to the patient. The physician will

decide if the patient should be given this infor-
Measuring and Recording mation. It is essential that vital signs be accurate.
Vital Signs They are often the first indication of a disease or
abnormality in the patient.
Vital signs are important indicators of health Temperature is a measurement of the bal-
states of the body. This unit discusses all of the ance between heat lost and heat produced by the
vital signs in detail. The basic information that body. Temperature can be measured in the mouth
follows serves as an introduction for this topic. (oral), rectum (rectal), armpit (axillary), ear
Vital signs are defined as various determi- (aural), or by the temporal artery in the forehead
nations that provide information about the basic (temporal). A low or high reading can indicate
body conditions of the patient. The four main disease. Most temperatures are measured in
vital signs are temperature, pulse, respirations, degrees on a thermometer that has a Fahrenheit
and blood pressure. Many health care profession- scale. However, some health care facilities are
als are now regarding the degree of pain as the now measuring temperature in degrees on a Cel-
fifth vital sign. Patients are asked to rate their sius (centigrade) scale. A comparison of the two
level of pain on a scale of 1 to 10, with 1 being scales is shown in figure 15-1 and in Appendix B.
minimal pain and 10 being severe pain. Other At times, it may be necessary to convert Fahren-
important vital signs that provide information heit temperatures to Celsius, or Celsius to Fahr-
about the patient’s condition include the color of enheit. The formulas for the conversion are as
the skin, the size of the pupils in the eyes and follows:
their reaction to light, the level of consciousness,
and the patient’s response to stimuli. As a health ♦ To convert Fahrenheit (F) temperatures
care worker, it will be your responsibility to mea- to Celsius (C) temperatures, subtract 32
sure and record the vital signs of patients. How- from the Fahrenheit temperature and then
ever, it is not in your realm of duties to reveal this multiply the result by 5/9, or 0.5556. For exam-
414 CHAPTER 15
94 96 98 100 102 104 106 108

the heart. The actual heartbeat is heard and
counted. At times, because of illness, hardening
Fahrenheit A reading of 98.6° F
Thermometer is the average
of the arteries, a weak or very rapid radial pulse,
98 100 “normal” Fahrenheit or doctor’s orders, you will be required to take an
temperature. apical pulse. Also, because infants and small chil-
dren have a very rapid radial pulse that is difficult
to count, apical pulses are usually taken.
34 35 36 37 38 39 40 41 42 43
If you note any abnormality or change in
any vital sign, it is your responsibility to
Celsius A reading of 37° C
Thermometer is the average
report this immediately to your supervisor. If you
36 37 38
“normal” Celsius have difficulty obtaining a correct reading, ask
temperature. another individual to check the patient. Never
guess or report an inaccurate reading.
FIGURE 15-1 Normal oral body temperature on
Fahrenheit and Celsius thermometers. STUDENT: Go to the workbook and complete
the assignment sheet for 15:1, Measuring and
ple, to convert a Fahrenheit temperature of Recording Vital Signs.
212 to Celsius, subtract 32 from 212 to get 180.
Then multiply 180 by 5/9, or 0.5556, to get the
Celsius temperature of 100.0.
15:2 INFORMATION
♦ To convert Celsius (C) temperatures to Measuring and Recording
Fahrenheit (F) temperatures, multiply Temperature
the Celsius temperature by 9/5, or 1.8, and
then add 32 to the total. For example, to con- Body temperature is one of the main vital
vert a Celsius temperature of 37 to Fahrenheit, signs. This section provides the basic guide-
multiply 37 by 9/5, or 1.8, to get 66.6. Then add lines for taking and recording temperature.
32 to 66.6 to get the Fahrenheit temperature of Temperature is defined as “the balance
98.6. between heat lost and heat produced by the
body.” Heat is lost through perspiration, respira-
Pulse is the pressure of the blood felt against tion, and excretion (urine and feces). Heat is pro-
the wall of an artery as the heart contracts and duced by the metabolism of food, and by muscle
relaxes, or beats. The rate, rhythm, and volume and gland activity. A constant state of fluid bal-
are recorded. Rate refers to the number of beats ance, known as homeostasis, is the ideal health
per minute, rhythm refers to regularity, and vol- state in the human body. The rates of chemical
ume refers to strength. The pulse is usually taken reactions in the body are regulated by body tem-
over the radial artery, although it may be felt over perature. Therefore, if body temperature is too
any superficial artery that has a bone behind it. high or too low, the body’s fluid balance is
Any abnormality can indicate disease. affected.
Respirations reflect the breathing rate of
the patient. In addition to the respiration count,
the rhythm (regularity) and character (type) of
respirations are noted. Abnormal respirations
VARIATIONS IN BODY
usually indicate that a health problem or disease TEMPERATURE
is present.
The normal range for body temperature is 97–
Blood pressure is the force exerted by the
100° Fahrenheit, or 36.1–37.8° Celsius (sometimes
blood against the arterial walls when the heart
called centigrade). However, variations in body
contracts or relaxes. Two readings (systolic and
temperature can occur. Some reasons for varia-
diastolic) are noted to show the greatest pressure
tions include:
and the least pressure. Both are very important.
Abnormal blood pressure is often the first indica- ♦ Individual Differences: some people have accel-
tion of disease. erated body processes and usually have higher
Another vital sign is the apical pulse. This temperatures; others have slower body pro-
pulse is taken with a stethoscope at the apex of cesses and usually have lower temperatures
Vital Signs 415
♦ Time of Day: body temperature is usually lower vides a measurement of body core temperature,
in the morning, after the body has rested and there is no normal range. Instead, the tempera-
higher in the evening, after muscular activity ture is calculated by the thermometer into an
and daily food intake have taken place equivalent of one of four usual settings: equal
mode, oral equivalent, rectal equivalent, or core
♦ Body Sites: parts of the body where tempera- equivalent. The equal mode provides no offset
tures are taken lead to variations; temperature
(adjustment) and is recommended for newborns,
variations by body site are shown in table
for whom axillary temperature is often taken. The
15-1.
oral equivalent is calculated with an offset; this
Oral temperatures are taken in the mouth. mode is used for adults and children over 3 years
The clinical thermometer is left in place for 3–5 of age, for whom oral readings are commonly
minutes. This is usually the most common, con- used. The rectal mode is calculated with an offset
venient, and comfortable method of obtaining a and is used mainly for infants up to 3 years of age,
temperature. Eating, drinking hot or cold liquids, for whom rectal temperatures are commonly
and/or smoking can alter the temperature in the taken. When the rectal mode is used on adults,
mouth. It is important to make sure the patient the temperature may read higher than average.
has not had anything to eat or drink, or has not The core equivalent is calculated with an offset
smoked for at least 15 minutes prior to taking the and measures core body temperatures such as
patient’s oral temperature. If the patient has done those found in the bladder or pulmonary artery.
any of these things, explain why you cannot take The core equivalent mode should only be used
the temperature and that you will return to do where adult “core” temperatures are commonly
so. used and should not be used for routine vital sign
Rectal temperatures are taken in the rec- measurements. Most aural thermometers record
tum. The clinical thermometer is left in place for temperature in less than 2 seconds; so this is a
3–5 minutes. This is an internal measurement fast and convenient method for obtaining tem-
and is the most accurate of all methods. Rectal perature. However, a drawback to using tympanic
temperatures are frequently taken on infants and thermometers is that inaccurate results will be
small children. obtained if the thermometer is not inserted into
Axillary temperatures are taken in the the ear correctly or if an ear infection or wax
armpit, under the upper arm. The arm is held buildup is present.
close to the body, and the thermometer is inserted Temporal temperatures are a newer way
between the two folds of skin. A groin tempera- to take temperature. A special temporal scanning
ture is taken between the two folds of skin formed thermometer is passed in a straight line across
by the inner part of the thigh and the lower abdo- the forehead, midway between the eyebrows and
men. Both axillary and groin are external temper- upper hairline. The thermometer measures the
atures and, thus, less accurate. The clinical temperature in the temporal artery to provide an
thermometer is held in place for 10 minutes. accurate measurement of blood temperature. A
Aural temperatures are taken with a spe- normal temporal temperature is similar to a rec-
cial tympanic thermometer that is placed in tal temperature, because it measures the temper-
the ear or auditory canal. The thermometer ature inside the body or bloodstream. Research
detects and measures the thermal, infrared has shown that temporal thermometers are more
energy radiating from blood vessels in the tym- accurate than other methods of taking tempera-
panic membrane, or eardrum. Because this pro- ture. Errors occur with clinical thermometers
TABLE 15-1 Temperature Variations by Body Site

ORAL RECTAL AND/OR TEMPORAL AXILLARY AND/OR GROIN
Average Temperature 98.6°F 99.6°F 97.6°F

(37°C) (37.6°C) (36.4°C)
Normal Range of Temperature 97.6–99.6°F 98.6–100.6°F 96.6–98.6°F
(36.5–37.5°C) (37–38.1°C) (36–37°C)
416 CHAPTER 15
because they are not inserted correctly, they are Bulb with
misread, or they are not left in place for the mercury Stem with calibrations
or alcohol
required period. Eating, drinking, smoking, and
other actions alter or change an oral temperature. 94 6 8 100 2 4 6 8 110
Perspiration or sweating alters or changes an axil- Oral thermometer

lary or groin temperature. These actions have no 94 6 8 100 2 4 6 8 110
effect on a temporal temperature. Because a tem- Security thermometer
poral scanning thermometer is easy to use and
94 6 8 100 2 4 6 8 110
produces accurate results, it will become a com- Rectal thermometer
mon way to record body temperature. FIGURE 15-2 Types of clinical thermometers.
♦ Causes of increased body temperature: illness,
bulb and is usually marked with a blue tip. A rec-
infection, exercise, excitement, and high tem-
tal thermometer has a short, stubby, rounded
peratures in the environment
bulb and may be marked with a red tip. In addi-
♦ Causes of decreased body temperature: starvation, some clinical thermometers have the word
tion or fasting, sleep, decreased muscle activ- “oral” or “rectal” written on their stems. Dispos-
ity, mouth breathing, exposure to cold able plastic sheaths may be used to cover the
temperatures in the environment, and certain thermometer when it is used on a patient.
diseases To avoid the chance of mercury contamina-
Very low or very high body temperatures are tion, the Occupational Health and Safety
indicative of abnormal conditions. Hypother- Administration (OSHA), the Environment Protec-
mia is a low body temperature, below 95°F (35°C) tion Agency (EPA), and the American Medical
measured rectally. It can be caused by prolonged Association (AMA) recommend the use of alco-
exposure to cold. Death usually occurs if body hol-filled thermometers or digital thermometers.
temperature drops below 93°F (33.9°C) for a If a clinical thermometer containing mercury
period of time. A fever is an elevated body tem- breaks, the mercury can evaporate and create a
perature, usually above 101°F (38.3°C) measured toxic vapor that can harm both humans and the
rectally. Pyrexia is another term for fever. The environment. Mercury poisoning attacks the
term febrile means a fever is present; afebrile central nervous system in humans. Children,
means no fever is present or the temperature is especially those under the age of six, are very sus-
within the normal range. Fevers are usually caused ceptible. Mercury can contaminate water sup-
by infection or injury. Hyperthermia occurs plies and build up in the tissues of fish and
when the body temperature exceeds 104°F (40°C) animals. Therefore, proper cleanup of a broken
measured rectally. It can be caused by prolonged clinical thermometer is essential. Never use a
exposure to hot temperatures, brain damage, and vacuum cleaner or broom to clean up mercury
serious infections. Immediate actions must be because this will break up the beads of mercury
taken to lower body temperature, because tem- and allow them to vaporize more quickly. Never
peratures above 106°F (41.1°C) can quickly lead to pour mercury down a drain or discard it in a toilet
convulsions, brain damage, and death. because this causes contamination of the water
supply. If a clinical thermometer breaks, close
doors to other indoor areas and open the win-
TYPES OF dows in the room with the mercury spill to vent
any vapors outside. Put on gloves and use two
THERMOMETERS cards or stiff paper to push the droplets of mer-
cury and broken glass into a plastic container
Clinical thermometers may be used to record with a tight-fitting lid. If necessary, use an eye-
temperatures. A clinical thermometer consists of dropper to pick up the balls of mercury. Shine a
a slender glass tube containing mercury or alco- flashlight in the area of the spill because the light
hol with red dye, which expands when exposed to will reflect off the shiny mercury beads and make
heat. There are different types of clinical ther- them easier to see. Wipe the entire area with a
mometers (figure 15-2). The glass oral thermom- damp sponge. Then place all cleanup material,
eter has a long, slender bulb or a blue tip. A including the paper, eyedropper, gloves, and
security oral thermometer has a shorter, rounder sponge, in the plastic container and label it “Mer-
Vital Signs 417
cury for Recycling.” Seal the lid tightly and take

the container to a mercury recycling center. Most
waste disposal companies will accept mercury
for recycling. To discard unbroken mercury ther-
mometers, place the intact thermometer in a
plastic container with a tight-fitting lid, label it,
and take it to a mercury recycling center.
Electronic thermometers are used in
many facilities. This type of thermometer regis-
ters the temperature on a viewer in a few seconds
(figure 15-3). Electronic thermometers can be
used to take oral, rectal, axillary, and/or groin
temperatures. Most facilities have electronic
thermometers with blue probes for oral use and FIGURE 15-4 Electronic digital thermometers are
red probes for axillary or rectal use. To prevent excellent for home use. (Courtesy of Omron Health-
cross-contamination, a disposable cover is placed care Inc., Vernon Hills, IL)
over the thermometer probe before the tempera-
ture is taken. By changing the disposable cover
after each use, one unit can be used on many
patients. Electronic digital thermometers are
excellent for home use because they eliminate
the hazard of a mercury spill that occurs when a
clinical thermometer is broken (figure 15-4). The
small battery-operated unit usually will register
the temperature in about 60 seconds on a digital
display screen. Disposable probe covers prevent
contamination of the probe.
Tympanic thermometers are specialized
electronic thermometers that record the aural FIGURE 15-5 Tympanic thermometers record the
aural temperature in the ear. Parts include: (A)
temperature in the ear (figure 15-5). A disposable
holder, (B) thermometer, and (C) disposable cover.
plastic cover is placed on the ear probe. By insert-
ing the probe into the auditory canal and push- read and follow instructions while using this ther-
ing a scan button, the temperature is recorded on mometer to obtain an accurate reading.
the screen within 1–2 seconds. It is important to Temporal scanning thermometers are
specialized electronic thermometers that mea-
sure the temperature in the temporal artery of
the forehead (figure 15-6). The thermometer
probe is placed on the forehead and passed in a
straight line across the forehead, midway between
the eyebrows and upper hairline. In this area, the
temporal artery is less than 2 millimeters (mm)
below the skin surface and easy to find. The tem-
perature registers on the screen in 1–2 seconds.
This thermometer provides an accurate measure-
ment of internal body temperature, is easy to use,
and is noninvasive. It is important to make sure
that the area of forehead scanned is not covered
by hair, a wig, or a hat. If the person’s head is lying
on a pillow, the side of the forehead by the pillow
should not be used for the measurement. Any
FIGURE 15-3 An electronic thermometer regis- type of head covering or a pillow prevents heat
ters the temperature in easy-to-read numbers on a from dissipating and causes the reading to be
viewer. falsely high.
418 CHAPTER 15
READING AND
RECORDING
TEMPERATURE
Electronic and tympanic thermometers are easy
to read because they have digital displays. Read-
ing a glass clinical thermometer is a procedure
that must be practiced. The thermometer should
be held at eye level and rotated slowly to find the
solid column of mercury or alcohol (figure 15-8).
The thermometer is read at the point where the
mercury or alcohol line ends. Each long line on a
thermometer is read as 1 degree. An exception to
this is the long line for 98.6°F (37°C), which is the
normal oral body temperature. Each short line
represents 0.2 (two-tenths) of a degree. Tempera-
FIGURE 15-6 Temporal scanning thermometers ture is always recorded to the next nearest two-
measure the temperature in the temporal artery of tenths of a degree. In figure 15-9, the line ends at
the forehead. (Courtesy of Exergen Corporation,
98.6°F (the inset explains the markings for each
Watertown, MA)
line).
Plastic or paper disposable thermometers are To record the temperature, write 986 instead
used in some health care facilities (figure 15-7). of 98.6. This reduces the possibility of mak-
These thermometers contain special chemical ing an error in reading. For example, a tempera-
dots or strips that change color when exposed to ture of 100.2 could easily be read as 102. By writing
specific temperatures. Some types are placed on 1002, the chance of error decreases. If a tempera-
the forehead and skin temperature is recorded. ture is taken orally, it is not necessary to indicate
Other types are used orally. Both types are used that it is an oral reading. If it is taken rectally,
once and discarded. place an (R) beside the recording. If it is taken in
the axillary area, place an (Ax) beside the record-
MATRIX
MATRIX
MATRIX
F
OFFF
O
O
0 24 6 8
00 2224446668 88
96
97
98
99
96
97
98
99
96
97
98
99
100
101
102
103
104
100
101
102
103
104
100
101
102
103
104
100
101
102
103
104
FIGURE 15-7 Plastic disposable thermometers FIGURE 15-8 A clinical thermometer must be
have chemical dots that change color to register held at eye level to find the solid column of mercury
body temperature. The matrix shown reads 101°F. or alcohol.
Vital Signs 419
2 4 6 8
10 10 10 10
98 99
Average
normal
94 9 104 106 108

98 FIGURE 15-10 A clinical thermometer can be
Mercury covered with a plastic sheath that is discarded after
column
each use.
FIGURE 15-9 Each line on a thermometer equals
two-tenths of a degree, so the thermometer shown
soaked in a disinfectant solution (frequently 70
reads 98.6°F. percent alcohol) for a minimum of 30 minutes
before it is used again. Other agencies cover the
ing. If it is taken tympanically (aurally), place an clinical thermometer with a plastic sheath that is
(A) beside the recording. For example: discarded after use (figure 15-10). The probe on
electronic thermometers is covered with a plastic
♦ 986 is an oral reading sheath that is discarded after each use. These
♦ 996 (R) is a rectal reading covers prevent the thermometers from coming
♦ 976 (Ax) is an axillary reading into contact with each patient’s mouth or skin
and prevent transmission of germs. Electronic
♦ 986 (A) is an aural reading thermometers all use disposable probes so con-
tamination of the thermometer is limited. Some
CLEANING health care facilities do use disinfectants to wipe
the outside of electronic thermometers. In most
THERMOMETERS cases, it is best to follow the recommendations of
the manufacturer for cleaning and proper care of
Thermometers must be cleaned thoroughly after electronic thermometers. Every health care
use. The procedure used varies with different worker should learn and follow the agency’s pol-
agencies and types of thermometers. In some icy for cleaning and care of thermometers.
agencies, the glass clinical thermometer is
washed and rinsed. Cool water is used to prevent STUDENT: Go to the workbook and complete
breakage and to avoid destroying the column of the assignment sheet for 15:2, Measuring and
mercury or alcohol. The thermometer is then Recording Temperature. Then return and continue
with the procedures.
PROCEDURE 15:2A
soaking basin with 70 percent alcohol, alco-
Cleaning a Clinical hol sponges or cotton balls, dry cotton balls
Thermometer or gauze pads, thermometer holder, dispos-
able gloves
Procedure
Clinical thermometer, soapy cotton balls,
small trash bag or waste can, running water, 1. Assemble equipment.
420 CHAPTER 15
PROCEDURE 15:2A
2. Wash hands. Put on gloves if needed. solution (usually 70 percent alcohol).
Make sure the thermometer is com-
CAUTION: Follow standard precau-
pletely covered by the solution (figure
tions. Wear gloves if the thermometer
15-11B).
was used for an oral or rectal tempera-
ture and was not covered with a plastic NOTE: Thirty minutes is usually the
sheath. minimum time recommended for soak-
ing.
3. After using the thermometer, use a
soapy cotton ball or gauze pad to wipe 7. Remove gloves and discard in an infec-
the thermometer once from the top tious waste container. Wash hands.
toward the tip or bulb (figure 15-11A).
8. After 30 minutes, remove the thermom-
Discard the soiled cotton ball in trash
eter from the soaking solution and use
bag or waste can.
an alcohol cotton ball or alcohol sponge
NOTE: Rotate the thermometer while to wipe it from the stem toward the bulb.
wiping it to clean all sides and parts. This removes any sediment from the
thermometer.
4. With the bulb pointed downward, hold
the thermometer by the stem and rinse 9. Rinse the thermometer in cool water.
the thermometer in cool water. Examine it carefully for any signs of
breakage. Discard any broken ther-
CAUTION: Hot water will break the
mometers according to the agency pol-
thermometer or destroy the mercury
icy for disposal of mercury or
column.
mercury-containing items.
5. Shake the thermometer down to 96°F
10. Read the thermometer to be sure it reads
(35.6°C) or lower.
96°F (35.6°C) or lower. Place it in a clean
CAUTION: Hold the thermometer gauze-lined container. It is now ready
securely between your thumb and index for use.
finger. Use a snapping motion of the
NOTE: Many health care agencies fill
wrist. Avoid countertops, tables, and
the container or thermometer holder
other surfaces.
with a disinfectant, usually 70 percent
6. Place the thermometer in a small basin alcohol.
or container filled with disinfectant
FIGURE 15-11A After each use, use a soapy FIGURE 15-11B Soak the thermometer in a
cotton ball or gauze to wipe the thermometer in disinfectant solution for a minimum of 30
a circular motion from the stem to the bulb. minutes.
Vital Signs 421
PROCEDURE 15:2A
12. Wash hands.
NOTE: This procedure may vary accord- Practice
ing to agency policy. Go to the workbook and use the
evaluation sheet for 15:2A, Cleaning
a Clinical Thermometer, to practice
Final Checkpoint Using the criteria you have mastered this skill, sign
listed on the evaluation sheet, your the sheet and give it to your
instructor will grade your performance. instructor for further action.
PROCEDURE 15:2B
mouth. Wait at least 15 minutes if the
Measuring and patient says “yes” to your question.
Recording Oral 5. Remove the clean thermometer by the
Temperature upper end. Use a clean tissue or dry cot-
ton ball to wipe the thermometer from
Equipment and Supplies stem to bulb.
Oral thermometer, plastic sheath (if used), NOTE: If the thermometer was soaking
holder with disinfectant solution, tissues or in a disinfectant, rinse first in cool
dry cotton balls, container for used tissues, water.
watch with second hand, soapy cotton balls, CAUTION: Hold the thermometer se-
disposable gloves, notepaper, pencil/pen curely to avoid breaking.
6. Read the thermometer to be sure it reads
Procedure 96°F (35.6°C) or lower. Check carefully
for chips or breaks.
CAUTION: Never use a cracked ther-
mometer because it may injure the
CAUTION: Follow standard precautions patient.
for contact with saliva or the mucous
7. If a plastic sheath is used, place it on the
membrane of the mouth.
thermometer.
8. Insert the bulb under the patient’s
tongue, toward the side of the mouth
4. Position the patient comfortably. Ask (figure 15-12). Ask the patient to hold it
the patient if he/she has eaten, has had in place with the lips, and caution
hot or cold fluids, or has smoked in the against biting it.
past 15 minutes.
NOTE: Check to be sure patient’s mouth
NOTE: Eating, drinking liquids, or smok- is closed.
ing can affect the temperature in the
422 CHAPTER 15
PROCEDURE 15:2B
CAUTION: Do not hold the bulb end.
This could alter the reading because of
the warmth of your hand.
11. Read the thermometer. Record the read-
ing on notepaper.
NOTE: Recheck the reading and your
notation for accuracy.
NOTE: If the reading is less than 97°F,
reinsert the thermometer in the patient’s
mouth for 1–2 minutes.
12. Clean the thermometer as instructed.
Shake down to 96°F (35.6°C) or lower for
next use.
13. Check the patient for comfort and safety
before leaving.
14. Replace all equipment.
15. Remove gloves and discard in infectious
waste container. Wash hands.
16. Record required information on the
FIGURE 15-12 Insert the bulb of the ther- patient’s chart or agency form, for exam-
mometer under the patient’s tongue (sublin-
ple, date and time, T 986, your signature
gually).
and title. Report any abnormal reading
to your supervisor immediately.
9. Leave the thermometer in place for 3–5
minutes.
NOTE: Some agencies require that a clin-
ical thermometer be left in place for 5–8
minutes. Follow your agency’s policy. Practice
NOTE: If an electronic thermometer is
evaluation sheet for 15:2B,
used, hold the thermometer in place
Measuring and Recording Oral
until the temperature registers on the
Temperature, to practice this
screen.
10. Remove the thermometer. Hold it by the have mastered this skill, sign the
stem and use a tissue or cotton ball to sheet and give it to your instructor
wipe toward the bulb. for further action.
NOTE: If a plastic sheath was used to
cover the thermometer, there is no need
to wipe the thermometer. Simply remove Final Checkpoint Using the criteria
the sheath, taking care not to touch the listed on the evaluation sheet, your
part that was in the patient’s mouth. instructor will grade your performance.
Vital Signs 423
PROCEDURE 15:2C
6. Turn the patient on his or her side. If
Measuring and possible, use Sims’ position (lying on
Recording Rectal left side with right leg bent up near the
Temperature abdomen). Infants are usually placed
on their backs, with legs raised and held
securely, or on their abdomens (figure
Equipment and Supplies 15-13).
Rectal thermometer, plastic sheath (if used), 7. Fold back covers just enough to expose
lubricant, tissues/cotton balls, waste bag or the anal area.
container, watch with second hand, paper,
pencil/pen, soapy cotton ball, disposable NOTE: Avoid exposing the patient
gloves unnecessarily.
NOTE: A manikin is frequently used to prac- 8. With one hand, raise the upper buttock
tice this procedure. gently. With the other hand, insert the
Procedure
CAUTION: Follow standard precautions
if contact with rectal discharge is possi-
ble.
Explain the procedure. Screen unit,
draw curtains, and/or close door to pro-
vide privacy for the patient.
4. Remove rectal thermometer from its
container. If the thermometer was soak-
ing in a disinfectant, hold it by the stem
end and rinse in cool water. Use a dry
tissue/cotton ball to wipe from stem to
bulb. Check that the thermometer reads
96°F (35.6°C) or lower. Check condition
of thermometer. If a plastic sheath is
used, position it on the thermometer.
CAUTION: Breaks in a thermometer can
injure the patient. Never use a cracked
thermometer.
5. Place a small amount of lubricant on
the tissue. Roll the bulb end of the ther-
mometer in the lubricant to coat it.
Leave the lubricated thermometer on
the tissue until the patient is properly
FIGURE 15-13 The infant can be positioned
positioned. on the back or abdomen for a rectal tempera-
ture.
424 CHAPTER 15
PROCEDURE 15:2C
lubricated thermometer approximately next to the recording to indicate a rectal
1 to 11⁄2 inches (1⁄2 to 1 inch for an infant) temperature was taken.
into the rectum. Tell the patient what
14. Reposition the patient. Observe all
you are doing.
safety checkpoints before leaving the
NOTE: At times, rotating the thermom- patient.
eter slightly will make it easier to insert.
15. Clean the thermometer as instructed in
CAUTION: Never force the thermome- Procedure 15:2A, Cleaning a Clinical
ter. It can break. If you are unable to Thermometer.
insert it, obtain assistance.
9. Replace the covers. Keep your hand on
17. Remove gloves and discard in infectious
the thermometer the entire time it is in
waste container. Wash hands.
place.
CAUTION: Never let go of the thermom-
patient’s chart or agency form, for exam-
eter. It could slide further into the rec-
ple, date and time, T 996 (R), your signa-
tum or break.
ture and title. Report any abnormal
10. Hold the thermometer in place for 3–5 reading immediately to your supervisor.
minutes.
NOTE: If an electronic thermometer is
used, hold the thermometer in place
until the temperature registers on the Practice
screen. Go to the workbook and use the
evaluation sheet for 15:2C,
11. Remove the thermometer gently. Tell Measuring and Recording Rectal
the patient what you are doing.
12. Remove plastic sheath, if used, and dis- procedure. When you believe you
card it or use a tissue to remove excess have mastered this skill, sign the
lubricant from the thermometer. Wipe sheet and give it to your instructor
from stem to bulb. Hold by the stem for further action.
area only. Discard the tissue into a waste
container.
13. Read and record. Recheck your reading listed on the evaluation sheet, your
for accuracy. Remember to place an (R) instructor will grade your performance.
PROCEDURE 15:2D
ond hand, paper, pencil/pen, soapy cotton
Measuring and ball
Recording Axillary
Temperature Procedure
2. Wash hands. Put on gloves if necessary.
Oral thermometer, plastic sheath (if used),
disposable gloves (if needed), tissues/cotton
balls, towel, waste container, watch with sec-
Vital Signs 425
PROCEDURE 15:2D
CAUTION: Follow standard precautions
if contact with open sores or body fluids
is possible.
4. Remove oral thermometer from its con-
tainer. Use a tissue to wipe from stem to
bulb. Check thermometer for damaged
areas. Read the thermometer to be sure
it reads below 96°F (36.5°C). Place a plas-
tic sheath on the thermometer, if used.
5. Expose the axilla and use a towel to pat
the armpit dry (figure 15-14A).
NOTE: Moisture can alter a temperature FIGURE 15-14B To take an axillary tempera-
reading. Do not rub area hard because ture, insert the bulb end of the thermometer in
this too can alter the reading. the hollow of the axilla or armpit.
CAUTION: Holding the bulb end will
6. Raise the patient’s arm and place the change the reading.
bulb end of the thermometer in the hol-
low of the axilla (figure 15-14B). Bring 9. Read and record. Check your reading for
the arm over the chest and rest the hand accuracy. Remember to mark (Ax) by the
on the opposite shoulder. recording to indicate axillary tempera-
ture.
NOTE: This position holds the ther-
mometer in place. 10. Reposition the patient. Be sure to check
for safety and comfort before leaving.
7. Leave the thermometer in place for 10
minutes. 11. Clean the thermometer as instructed.
NOTE: If an electronic thermometer is 12. Replace all equipment used.
used, hold the thermometer in place 13. Remove gloves if worn and discard in an
until the temperature registers on the infectious waste container. Wash hands.
screen.
8. Remove the thermometer. Remove patient’s chart or agency form, for exam-
sheath, if used, and discard. Wipe from ple, date and time, T 976 (Ax), your signa-
stem to bulb to remove moisture. Hold ture and title. Report any abnormal
by the stem end only. reading immediately to your supervisor.
Practice
evaluation sheet for 15:2D,
Measuring and Recording Axillary
for further action.

FIGURE 15-14A Before taking an axillary listed on the evaluation sheet, your
temperature, use a towel to pat the armpit dry. instructor will grade your performance.
426 CHAPTER 15
PROCEDURE 15:2E
the parent’s lap, with the head held
Measuring and against the parent’s chest for support.
Recording Tympanic Adults who can cooperate and hold the
(Aural) Temperature head steady can either sit or lie flat.
Patients in bed should have the head
turned to the side, and stabilized against
Equipment and Supplies the pillow.
Tympanic thermometer, probe cover, paper, 7. Hold the thermometer in your right
pencil/pen, container for soiled probe cover hand to take a temperature in the right
ear, and in your left hand to take a tem-
Procedure perature in the left ear. With your other
hand, pull the ear pinna (external lobe)
1. Assemble equipment. up and back on any child over 1 year of
NOTE: Read the operating instructions age and on adults (figure 15-15A). Pull
so you understand exactly how the ther- the ear pinna straight back for infants
mometer must be used. under 1 year of age.
2. Wash hands. Put on gloves if needed. NOTE: Pulling the pinna correctly
straightens the auditory canal so the
CAUTION: Follow standard precautions probe tip will point directly at the tym-
if contact with open sores or body fluids panic membrane.
is possible.
8. Insert the covered probe into the ear
3. Introduce yourself. Identify the patient. canal as far as possible to seal the canal
Explain the procedure. (figure 15-15B). Do not apply pressure.
4. Remove the thermometer from its base.
Set the thermometer on the proper
mode according to operating instruc-
tions. The equal mode is usually used
for newborn infants, the rectal mode for
children under 3 years of age, and the
oral mode for children over 3 years of
age and all adults. In areas where core
body temperatures are recorded, such
as critical care units, the core mode may
be used.
5. Install a probe cover according to
instructions. This will usually activate
the thermometer, showing the mode
selected and the word ready, indicating
the thermometer is ready for use.
CAUTION: Do not use the thermometer
until ready is displayed because inaccu-
rate readings will result.
6. Position the patient. Infants under 1
year of age should be positioned lying FIGURE 15-15A Before inserting the tym-
flat with the head turned for easy access panic thermometer, pull the pinna up and back
to the ear. Small children can be held on on adults and children older than 1 year.
Vital Signs 427
PROCEDURE 15:2E
CAUTION: If the temperature reading is
low or does not appear to be accurate,
change the probe cover and repeat the
procedure. The opposite ear can be used
for comparison.
11. Press the eject button on the thermom-
eter to discard the probe cover into a
waste container.
12. Return the thermometer to its base.
patient.
14. Remove gloves if worn and discard in an
infectious waste container. Wash
hands.
ple, date and time, T 98° (A), your signa-
FIGURE 15-15B After inserting the covered ture and title. Report any abnormal
probe of the tympanic thermometer into the ear reading immediately to your supervisor.
canal, press the scan or activation button and
hold the thermometer steady until the tempera-
ture reading is displayed.
9. Rotate the thermometer handle slightly Practice

until it is aligned with the patient’s jaw. Go to the workbook and use the
Hold the thermometer steady and press evaluation sheet for 15:2E,
the scan or activation button. Hold it for Measuring and Recording
the required amount of time, usually 1– Tympanic (Aural) Temperature, to
2 seconds, until the reading is displayed practice this procedure. When you
on the screen. believe you have mastered this skill,
10. Remove the thermometer from the sign the sheet and give it to your
patient’s ear. Read and record the tem- instructor for further action.
perature. Place an (A) by the recording
to indicate tympanic temperature.
NOTE: The temperature will remain on Final Checkpoint Using the criteria
the screen until the probe cover is listed on the evaluation sheet, your
removed. instructor will grade your performance.
428 CHAPTER 15
PROCEDURE 15:2F
push the button to turn on the ther-
Measuring mometer.
Temperature with an 6. Cover the probe with the sheath or
Electronic probe cover.
Thermometer NOTE: For a rectal temperature, the
sheath must be lubricated.
Equipment and Supplies 7. Insert the covered probe into the desired
location. Most probes are heavy, so it is
Electronic thermometer with probe, sheath
usually necessary to hold the probe in
(probe cover), paper, pen/pencil, container
position (figure 15-16A).
for soiled sheath
CAUTION: Hold on to the probe at all
Procedure times for a rectal temperature.
8. When the unit signals that the tempera-
1. Assemble equipment. ture has been recorded, remove the
NOTE: Read the operating instructions probe.
for the electronic thermometer so you NOTE: Many electronic thermometers
understand how the particular model have an audible “beep.” Others indicate
operates. that temperature has been recorded
2. Wash hands. Put on gloves if needed.
tions. Always wear gloves if you are tak-
ing a rectal temperature.
NOTE: Many health care facilities do not
require gloves for an oral temperature
taken with an electronic thermometer
because there is usually no contact with
oral fluids. Follow agency policy.
4. Position the patient comfortably and
correctly.
NOTE: For an oral temperature, ask the
patient if he/she has eaten, has had hot
or cold fluids, or has smoked in the past
15 minutes. Wait at least 15 minutes if
the patient answers “yes.”
NOTE: For a rectal temperature, posi-
tion the patient in Sims’ position if pos-
sible.
5. If the probe has to be connected to the
thermometer unit, insert the probe into FIGURE 15-16A While taking a temperature,
the correct receptacle. If the thermom- hold the probe of the electronic thermometer in
eter has an “on” or “activate” button, place.
Vital Signs 429
PROCEDURE 15:2F
when the numbers stop flashing and ton that is pushed to remove the
become stationary. sheath.
9. Read and record the temperature. 11. Reposition the patient. Observe all
Recheck your reading for accuracy. safety checkpoints before leaving the
patient.
NOTE: Remember to place an (R) next
to rectal readings or an (Ax) next to axil- 12. Return the probe to the correct storage
lary readings. position in the thermometer unit. Turn
off the unit if this is necessary. Place the
10. Without touching the sheath or probe
unit in the charging stand if the model
cover, discard the sheath in an infec-
has a charging unit.
tious waste container (figure 15-16B).
Most thermometers have an eject but- 13. Replace all equipment.
14. Remove gloves if worn and discard in an
infectious waste container. Wash
hands.
ple, date and time, T 988, your signature
and title. Report any abnormal reading
immediately to your supervisor.
Practice
evaluation sheet for 15:2F,
Measuring Temperature with an
Electronic Thermometer, to practice
FIGURE 15-16B Discard the probe cover in Final Checkpoint Using the criteria
an infectious waste container without touching listed on the evaluation sheet, your
the cover. instructor will grade your performance.
430 CHAPTER 15
PROCEDURE 15:2G
If the patient was lying on a pillow, do
Measuring and not use the side of the forehead that was
Recording Temporal on the pillow.
Temperature CAUTION: Head coverings or a pillow
prevent heat from dissipating from the
Equipment and Supplies forehead and cause a falsely high tem-
perature reading.
Temporal scanning thermometer, paper,
7. Gently position the probe flat on the
pen/pencil
center of the forehead, midway between
the eyebrow and hairline. Press and hold
Procedure the scan button.
1. Assemble equipment. 8. Slide the thermometer across the fore-
head lightly and slowly (figure 15-17).
NOTE: Read the operating instructions
Keep the sensor flat and in contact with
for the temporal scanning thermometer
the skin until you reach the hairline on
so you understand how the particular
the side of the face.
model works.
NOTE: The thermometer will emit a
2. Wash hands.
beeping sound and a red light will blink
3. Introduce yourself. Identify the patient. to indicate that a measurement is taking
Explain the procedure. place.
4. Remove the protective cap on the lens 9. Release the scan button and remove the
of the thermometer. Hold the thermom- thermometer from the head.
eter upside down to clean the lens with
an alcohol wipe and allow it to dry.
Check the lens for cleanliness after it
has dried.
NOTE: Holding the thermometer upside
down prevents excess moisture from
entering the sensor area. The moisture
will not harm the sensor, but a tempera-
ture cannot be taken until the sensor
lens is dry.
5. Position the patient comfortably. Adults
who can cooperate and hold the head
steady can either sit or lie flat. Infants
younger than 1 year should be posi-
tioned lying flat on the back. Small chil-
dren can be held on the parent’s lap,
with the head held against the parent’s
chest for support, or lying flat.
6. Check the forehead to make sure there FIGURE 15-17 To take a temporal tempera-
is no sign of perspiration. If perspiration ture, hold the scan button while lightly sliding
is present, use a towel to pat the fore- the thermometer across the forehead midway
head dry. Make sure no covering, such between the eyebrow and hairline. (Courtesy of
as a hat, wig, or hair, is on the forehead. Exergen Corporation, Watertown, MA)
Vital Signs 431
PROCEDURE 15:2G
NOTE: If sweating is profuse and you 14. Wash hands.
are not able to dry the forehead com-
pletely, scan the temperature as normal
but keep the scan button depressed
ple, date and time, T 998, your signature,
when the thermometer is removed from
and your title. Report any abnormal
the forehead. Immediately nestle the
reading immediately to your supervisor.
thermometer on the neck directly
behind the earlobe. Release the button
and read the temperature.
10. Read and record the temperature that is
displayed on the thermometer. Double-
check your reading. Practice
11. Press and release the activation button Go to the workbook and use the
quickly to turn off the thermometer. Put evaluation sheet for 15:2G,
the protective cap on the lens to protect Measuring and Recording Temporal
the lens. Temperature, to practice this
NOTE: Most thermometers will turn off
automatically after 30 seconds to 1 min-
ute.
for further action.
patient.
13. Replace all equipment. Wipe the outside Final Checkpoint Using the criteria
of the thermometer with an alcohol listed on the evaluation sheet, your
wipe or disinfectant. instructor will grade your performance.
♦ Carotid: at the neck on either side of the tra-

15:3 INFORMATION chea
Measuring and Recording Pulse ♦ Brachial: inner aspect of forearm at the ante-
cubital space (crease of the elbow)
Pulse is a vital sign that you will be required
to take. There are certain facts you must ♦ Radial: at the inner aspect of the wrist, above
know when you take this measurement. This sec- the thumb
tion provides the main information. ♦ Femoral: at the inner aspect of the upper thigh
Pulse refers to the pressure of the blood where the thigh joins with the trunk of the
pushing against the wall of an artery as the body
heart beats and rests. In other words, it is a throb-
bing of the arteries that is caused by the contrac-
♦ Popliteal: behind the knee
tions of the heart. The pulse is more easily felt in ♦ Dorsalis pedis: at the top of the foot arch
arteries that lie fairly close to the skin and can be
pressed against a bone by the fingers. NOTE: Pulse is usually taken over the radial
The pulse can be felt at different arterial sites artery.
on the body. Some of the major sites are shown in
Each time a pulse is measured, three different
figure 15-18 and include:
facts must be noted: the rate, the rhythm, and the
♦ Temporal: on either side of the forehead volume of the pulse. These facts are important to
432 CHAPTER 15
Temporal Temporal ♦ Adult men: 60–70 beats per minute

artery artery
♦ Adult women: 65–80 beats per minute
Carotid Carotid ♦ Children aged over 7: 70–100 beats per
artery artery minute
♦ Children aged from 1–7: range of 80–110 beats
per minute
♦ Infants: 100–160 beats per minute
Brachial
artery
Brachial
artery
♦ Bradycardia: a pulse rate under 60 beats per
minute
♦ Tachycardia: a pulse rate over 100 beats per
Radial Radial minute (except in children)
artery artery
NOTE: Any variations or extremes in pulse rates
Femoral Femoral should be reported immediately.
artery artery
Rhythm of the pulse is also noted. Rhythm
Popliteal artery Popliteal artery refers to the regularity of the pulse, or the spacing
(behind the knee) (behind the knee) of the beats. It is described as regular or irregular.
An arrhythmia is an irregular or abnormal
rhythm, usually caused by a defect in the electri-
cal conduction pattern of the heart.
Volume, or the strength or intensity of the
Dorsalis pedis artery Dorsalis pedis artery pulse, is also noted. It is described by words such
(pedal pulse) (pedal pulse)
as strong, weak, thready, or bounding.
Various factors will change pulse rate.
FIGURE 15-18 Major pulse sites. Increased, or accelerated, rates can be caused by
exercise, stimulant drugs, excitement, fever,
provide complete information about the pulse.
shock, nervous tension, and other similar factors.
For example, a pulse of 82, strong and regular, is
Decreased, or slower, rates can be caused by
much different than a pulse of 82, weak and very
sleep, depressant drugs, heart disease, coma,
irregular.
physical training, and other similar factors.
The rate of the pulse is measured as the num-
ber of beats per minute. Pulse rates vary among
individuals, depending on age, sex, and body size:
the assignment sheet for 15:3, Measuring and
♦ Adults: general range of 60–100 beats per Recording Pulse. Then return and continue with
minute the procedure.
PROCEDURE 15:3
2. Wash hands.
Measuring and
Recording Radial Pulse Explain the procedure.
Equipment and Supplies 4. Place the patient in a comfortable posi-

tion, with the arm supported and the
Watch with second hand, paper, pencil/pen palm of the hand turned downward.
NOTE: If the forearm rests on the chest,
Procedure it will be easier to count respirations
after taking the pulse.
Vital Signs 433
PROCEDURE 15:3
5. With the tips of your first two or three 8. Record the following information: date,
fingers, locate the pulse on the thumb time, rate, rhythm, and volume. Follow
side of the patient’s wrist (figure 15-19). your agency’s policy for recording.
NOTE: Do not use your thumb; use your 9. Check the patient before leaving.
fingers. The thumb contains a pulse that Observe all safety precautions to protect
you may confuse with the patient’s the patient.
pulse.
6. When the pulse is felt, exert slight pres-
11. Wash hands.
sure and start counting. Use the second
hand of the watch and count for 1 full 12. Record all required information on the
minute. patient’s chart or agency form, for exam-
ple, date, time, P 82 strong and regular,
NOTE: In some agencies, the pulse is
your signature and title. Report any
counted for 30 seconds and the final
unusual observations immediately to
number multiplied by 2. To detect irreg-
your supervisor.
ularities, it is better to count for 1 full
minute.
7. While counting the pulse, also note the
volume (character or strength) and the
rhythm (regularity).
Practice
evaluation sheet for 15:3, Measuring
and Recording Radial Pulse, to
sign the sheet and give it to your
FIGURE 15-19 To count a radial pulse, put Final Checkpoint Using the criteria
the tips of two or three fingers on the thumb listed on the evaluation sheet, your
side of the patient’s wrist. instructor will grade your performance.
15:4 INFORMATION Respiration is the process of taking in oxy-

gen (O2) and expelling carbon dioxide (CO2)
Measuring and Recording from the lungs and respiratory tract. One respira-
tion consists of one inspiration (breathing in) and
Respirations one expiration (breathing out).
Respirations are another vital sign that you Each time respiration is measured, three dif-
must observe, count, and record correctly. ferent facts must be noted: the rate, the character,
This section provides the main points you must and the rhythm of respirations. These three facts
note when counting and recording the quality of provide complete information about how the
respirations. patient is breathing. For example, a respiration
434 CHAPTER 15
measurement of 18, deep and regular, is much ♦ Cheyne–Stokes: abnormal breathing pattern
different than a measurement of 18, very shallow characterized by periods of dyspnea followed
and irregular. by periods of apnea; frequently noted in the
Rate of respirations counts the numbers of dying patient
breaths per minute. The normal rate for respira-
tions in adults is a range of 12–20 breaths per min-
♦ Rales: bubbling or noisy sounds caused by
fluids or mucus in the air passages
ute. In children, respirations are slightly faster
than those for adults and average 16–30 per min- ♦ Wheezing: difficult breathing with a high-
ute. In infants, the rate may be 30–50 per minute. pitched whistling or sighing sound during
In addition to rate, the character and rhythm expiration; caused by a narrowing of bronchi-
of respirations should be noted. Character oles (as seen in asthma) and/or an obstruc-
refers to the depth and quality of respirations. tion or mucus accumulation in the bronchi
Words used to describe character include deep, ♦ Cyanosis: a dusky, bluish discoloration of the
shallow, labored, difficult, stertorous (abnormal skin, lips, and/or nail beds as a result of
sounds like snoring), and moist. Rhythm refers to decreased oxygen and increased carbon diox-
the regularity of respirations, or equal spacing ide in the bloodstream
between breaths. It is described as regular or
irregular. Respirations must be counted in such a way
The following terminology is used to describe that the patient is unaware of the procedure.
abnormal respirations: Because respirations are partially under volun-
tary control, patients may breathe more quickly
♦ Dyspnea: difficult or labored breathing or more slowly when they become aware of the
fact that respirations are being counted. Do not
♦ Apnea: absence of respirations, usually a tell the patient you are counting respirations.
temporary period of no respirations
Also, leave your hand on the pulse site while
♦ Tachypnea: rapid, shallow respiratory rate counting respirations. The patient will think you
above 25 respirations per minute are still counting pulse and will not be likely to
alter the respiratory rate.
♦ Bradypnea: slow respiratory rate, usually
below 10 respirations per minute
♦ Orthopnea: severe dyspnea in which breath- the assignment sheet for 15:4, Measuring and
ing is very difficult in any position other than Recording Respirations. Then return and continue
sitting erect or standing with the procedure.
PROCEDURE 15:4
Measuring and
4. After the pulse rate has been counted,
Recording leave your hand in position on the pulse
Respirations site and count the number of times the
chest rises and falls during 1 minute
Equipment and Supplies (figure 15-20).
NOTE: This is done so the patient is not
Watch with second hand, paper, pen/pencil
aware that respirations are being
counted. If patients are aware, they can
Procedure alter their rate of breathing.
1. Assemble equipment. 5. Count each expiration and inspiration
as one respiration.
2. Wash hands.
Vital Signs 435
PROCEDURE 15:4
8. Check the patient before leaving the
area. Observe all safety precautions to
protect the patient.
10. Wash hands.
11. Record all required information on the
ple, date, time, R 16 deep and regular (or
even), your signature and title. Report
any unusual observations immediately
to your supervisor.
Practice
FIGURE 15-20 Positioning the patient’s hand evaluation sheet for 15:4, Measuring
on his or her chest makes it easier to count and Recording Respirations, to
pulse and respiration. practice this procedure. When you
6. Note the depth (character) and rhythm
(regularity) of the respirations.
7. Record the following information: date, listed on the evaluation sheet, your
time, rate, character, and rhythm. instructor will grade your performance.
Some charts make use of color coding. For

15:5 INFORMATION example, temperature is recorded in blue ink,
pulse is recorded in red ink, and respirations are
Graphing TPR recorded in green ink. Other agencies use blue ink
In some agencies, you may be required to for 7 A.M. to 7 P.M. (days) and red ink for 7 P.M. to 7
chart temperature, pulse, and respirations A.M. (nights). Follow the policy of your institution.
(TPR) on graphic records. This section provides Factors that affect vital signs are often
basic information about these records. included on the graph. Examples include surgery,
Graphic sheets are special records used for medications that lower temperature (such as
recording temperature, pulse, and respirations. aspirin), and antibiotics.
The forms vary in different health care facilities, The graph is a medical record, so it must be
but all contain the same basic information. The neat, legible, and accurate. Double-check
graphic chart presents a visual diagram of varia- all information recorded on the graph. If an error
tions in a patient’s vital signs. The progress is eas- occurs, it should be crossed out carefully with red
ier to follow than a list of numbers that give the ink and initialed. Correct information should
same information. Graphic charts are used most then be inserted on the graph.
often in hospitals and long-term-care facilities.
However, similar records may be kept in medical STUDENT: Read the complete procedure for
offices or other health care facilities. Patients are 15:5, Graphing TPR. Then go back and start doing
sometimes taught how to maintain these records. the procedure. Your assignment will follow the
procedure.
436 CHAPTER 15
PROCEDURE 15:5
sheets contain time blocks across the
Graphing TPR top and number blocks for TPRs on the
side. Note areas for recording tempera-
Equipment and Supplies ture, pulse, and respirations. Refer to
the example while completing the pro-
Blank TPR graphic sheets in the workbook, cedure steps.
TPR sample graph, assignment sheets on
graphing in the workbook, pen, ruler 3. Using a blank graphic sheet, fill in
patient information in the spaces pro-
Procedure vided at the top. Write last name first in
most cases. Be sure patient identifica-
1. Assemble equipment. tion, hospital, and room number are
accurate.
2. Examine the sample graphic sheet (fig-
ure 15-21). This will vary, depending on NOTE: Forms vary. Follow directions as
the agency. However, most graphic they apply to your form.
GRAPHIC CHART
Family Name First Name Attending Physician Room No. Hosp. No.
DOE JOHN DR. JOHN JONES 238 142-555
Date
2/1/0 – 2/2/0 – 2/3/0– 2/4/0– 2/5/0– 2/6/0– 2/7/0– 2/8/0 –
Day in Hospital
ADM 1 2 3 4 5 6 7
Day P.O. or P.P. O.R. 1 2 3 4 5
Hour A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M.
4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12
ASPIRIN GRX
106
105
SUR GER Y
104
TEMPERATURE
103 R
ADMITTED
102
R AX
101 R
100 R
R
99
Normal AX
98
97
96
150
140
130
120
PULSE
110
100
90
80
70
60
50
RESPIRATION
40
30
20
10
Blood Pressure 128/74 136/78 130/76 130/74

Fluid Intake 1850cc.
Urine 1545cc.
Defecation
Weight 158
FIGURE 15-21 A sample graphic sheet.

Vital Signs 437
PROCEDURE 15:5
4. Fill in the dates in the spaces provided 11. Any drug that might alter or change
after DATE. temperature or other vital sign is usually
NOTE: A graphic chart provides a day- noted on the graph in the time column
to-day visual representation of the vari- closest to the time when the drug was
ations in a patient’s TPRs. first given. Turn the paper sideways and
write the name of the drug in the correct
5. If your chart calls for DAY IN HOSPITAL time column. Aspirin is often recorded
below the dates, enter Adm under the in this column because it lowers tem-
first date. This stands for day of admis- perature. A rapid drop in body tempera-
sion. The second date would then be ture would be readily explained by the
day 1, or first full day in the hospital. The word aspirin in the time column. Anti-
third date would be day 2, and so forth. biotics and medications that alter heart
6. Some graphs contain a third line, DAYS PO rate are also noted in many cases.
or PP, which means days post-op (after 12. Other events in a patient’s hospitaliza-
surgery) or postpartum (after delivery of tion are also recorded in the time col-
a baby). The day of surgery would be umn. Examples include surgery and
shown as OR or Surgery. The next day discharge. In some hospitals, if the
would be day 1, or first day after surgery. patient is placed in isolation, this is also
The day of delivery of a baby is shown as noted on the graph.
Del, with the next day as day 1, or first
day after delivery. Numbers continue in 13. Blood pressure, weight, height, defeca-
sequence for each following day. tion (bowel movements), and other
similar kinds of information are often
7. Go to the Assignment Sheet #1. Note the recorded in special areas at the bottom
TPRs. On the graphic sheet, find the cor- of the graphic record. Record any infor-
rect Date and Time column. Move down mation required in the correct areas on
the column until the correct temperature your form.
number is found on the side of the chart.
Mark this with a dot (•) in the box. Do the 14. Recheck your graph for neatness, accu-
same for the pulse and respirations. racy, and completeness of information.
CAUTION: Double-check your nota-

tions. Be sure they are accurate.
CHECKPOINT: Your instructor will
check your notations. Practice
8. Repeat step 7 for the next TPR. Check to Go to the workbook and complete
be sure you are in the correct time col- Assignment Sheet #1 for Graphing
umn. Mark the dots clearly under the TPR. Give it to your instructor for
time column and at the correct temper- grading. Note all changes. Then
ature measurement, pulse rate, or respi- complete Assignment Sheet #2 for
ration rate. Graphing TPR in the workbook.
9. Use a straight paper edge or ruler to Repeat this process by completing
connect the dots for temperature. Do Graphing TPR assignments #3 to #5
the same with the dots for pulse and, until you have mastered graphic
finally, with the dots for respiration. records.
NOTE: A ruler makes the line straight and
neat, and the readings are more legible.
10. Continue to graph the remaining TPRs Final Checkpoint Your instructor will
from Assignment Sheet #1. Double-check grade your performance on this skill
all entries for accuracy. Use a ruler to con- according to the accuracy of the com-
nect all dots for each of the vital signs. pleted assignments.
438 CHAPTER 15
15:6 INFORMATION
Measuring and Recording
Apical Pulse
An apical pulse is a pulse count taken with a
stethoscope at the apex of the heart. The actual
heartbeat is heard and counted. A stethoscope
is an instrument used to listen to internal body
sounds. The stethoscope amplifies the sounds so
they are easier to hear. Parts of the stethoscope
include the earpieces, tubing, and bell or thin,
flexible disk called a diaphragm (figure 15-22). FIGURE 15-23 An apical pulse is frequently
The tips of the earpieces should be bent forward taken on infants and small children because their
when they are placed in the ears. The earpieces pulses are more rapid.
should fit snugly but should not cause pain or
discomfort. To prevent the spread of microorgan-
isms, the earpieces and bell/diaphragm of the Two separate heart sounds are heard while
stethoscope should be cleaned with a disinfec- listening to the heartbeat. The sounds
tant such as alcohol before and after every use. resemble a “lubb-dupp.” Each lubb-dupp counts
Usually, a physician orders an apical pulse. It as one heartbeat. The sounds are caused by the
is frequently ordered for patients with irregular closing of the heart valves as blood flows through
heartbeats, hardening of the arteries, or weak or the chambers of the heart. Any abnormal sounds
rapid radial pulses. Because children and infants or beats should be reported immediately to your
have very rapid radial pulse counts, apical pulse supervisor.
counts are usually taken (figure 15-23). It is gen- A pulse deficit is a condition that occurs
erally easier to count a rapid pulse while listening with some heart conditions. In some cases,
to it through a stethoscope than by feeling it with the heart is weak and does not pump enough
your fingers. blood to produce a pulse. In other cases, the heart
It is important that you protect the patient’s beats too fast (tachycardia), and there is not
privacy when counting an apical pulse. Avoid enough time for the heart to fill with blood; there-
exposing the patient during this procedure.
Earpieces
Diaphragm
Chest
piece
Bell
Rubber
or
plastic
tubing
FIGURE 15-24 To determine a pulse deficit, one
person should count an apical pulse while another
FIGURE 15-22 Parts of a stethoscope. person is counting a radial pulse.
Vital Signs 439
fore, the heart does not produce a pulse during the radial pulse from the rate of the apical pulse.
each beat. In such cases, the apical pulse rate is The difference is the pulse deficit. For example, if
higher than the pulse rate at other pulse sites on the apical pulse is 130 and the radial pulse is 92,
the body. For the most accurate determination of the pulse deficit would be 38 (130 – 92 38).
a pulse deficit, one person should check the api-
cal pulse while a second person checks another STUDENT: Go to the workbook and complete
pulse site, usually the radial pulse (figure 15-24). the assignment sheet for 15:6, Measuring and
If this is not possible, one person should first Recording Apical Pulse. Then return and continue
check the apical pulse and then immediately with the procedure.
check the radial pulse. Then, subtract the rate of
PROCEDURE 15:6
6. Place the stethoscope tips in your ears.
Measuring and Locate the apex of the heart, 2–3 inches
Recording Apical Pulse to the left of the breastbone. Use your
index finger to locate the fifth intercostal
Equipment and Supplies (between the ribs) space at the midcla-
vicular (collarbone) line (figure 15-25).
Stethoscope, watch with second hand, paper, Place the bell/diaphragm over the apical
pencil/pen, alcohol or disinfectant swab region and listen for heart sounds.
CAUTION: Be sure the tips of the stetho-
Procedure scope are facing forward before placing
them in your ears.
1. Assemble equipment. Use alcohol or a
disinfectant to wipe the earpieces and
Mid-clavicular
the bell/diaphragm of the stethoscope.
2. Wash hands.
3. Introduce yourself. Identify the patient 1
and explain the procedure. If the patient 2
is an infant or child, explain the proce- 3
dure to the parent(s). 4
NOTE: It is usually best to say, “I am 5
going to listen to your heartbeat.” Some 5th

patients do not know what an apical Intercostal
space
pulse is.
4. Close the door to the room. Screen the Apex
unit or draw curtains around the bed to
provide privacy.
5. Uncover the left side of the patient’s
chest. The stethoscope must be placed
directly against the skin.
NOTE: If the diaphragm of the stetho- FIGURE 15-25 Locate the apex of the heart
scope is cold, warm it by placing it in the at the fifth intercostal (between the ribs) space
palm of your hand before placing it on by the midclavicular (middle of the collarbone)
the patient’s chest. line.
440 CHAPTER 15
PROCEDURE 15:6
7. Count the apical pulse for 1 full minute. 12. Wash hands.
Note the rate, rhythm, and volume.
NOTE: Remember to count each lubb- patient’s chart or agency form. For
dupp as one beat. example: date, time, AP 86 strong and
regular, your signature and title. If any
8. If you doubt your count, recheck your
abnormalities or changes were observed,
count for another minute.
note and report these immediately.
9. Record your reading. Note date, time,
rate, rhythm, and volume. Chart accord-
ing to the agency policy. Some use an A
and others use an AP to denote apical
pulse.
NOTE: If both a radial and apical pulse Practice
are taken, it may be recorded as A82/ Go to the workbook and use the
R82. If a pulse deficit exists, it should be evaluation sheet for 15:6, Measuring
noted. For example, with A80/R64, there and Recording Apical Pulse, to
is a pulse deficit of 16 (that is, 80 – 64 practice this procedure. When you
16). This would be recorded as A80/R64 believe you have mastered this skill,
Pulse deficit: 16. sign the sheet and give it to your
10. Check all safety and comfort points instructor for further action.
before leaving the patient.
11. Use an alcohol or disinfectant swab to
clean the earpieces and the bell/dia-
phragm of the stethoscope. If the tubing
contacted the patient’s skin, wipe the Final Checkpoint Using the criteria
tubing with a disinfectant. Replace all listed on the evaluation sheet, your
equipment. instructor will grade your performance.
15:7 INFORMATION sure occurs in the walls of the arteries when the
left ventricle of the heart is contracting and push-
Measuring and Recording ing blood into the arteries. Diastolic pressure is
the constant pressure in the walls of the arteries
Blood Pressure when the left ventricle of the heart is at rest, or
Blood pressure (BP) is one of the vital signs between contractions. Blood has moved forward
you will be required to take. It is important into the capillaries and veins, so the volume of
that your recording be accurate and that you blood in the arteries has decreased.
understand what the blood pressure reading Normal values and classifications for diastolic
means. and systolic pressure are shown in table 15-2.
Blood pressure is a measurement of the Blood pressure is recorded as a fraction. The
pressure that the blood exerts on the walls systolic reading is the top number, or numerator.
of the arteries during the various stages of heart The diastolic reading is the bottom number, or
activity. Blood pressure is read in millimeters denominator. For example, a systolic reading of
(mm) of mercury (Hg) on an instrument known 120 and a diastolic reading of 80 is recorded as
as a sphygmomanometer. 120/80.
There are two types of blood pressure mea- Pulse pressure is the difference between
surements: systolic and diastolic. Systolic pres- systolic and diastolic pressure. The pulse
Vital Signs 441
TABLE 15-2 Classifications of Blood Pressure systolic and 60 mm Hg diastolic. Hypotension

in Adults may occur with heart failure, dehydration,
depression, severe burns, hemorrhage, and
Blood Pressure Level shock. Orthostatic, or postural, hypotension
Millimeters of Mercury (mm Hg) occurs when there is a sudden drop in both sys-
tolic and diastolic pressure when an individual
Category Systolic Diastolic
moves from a lying to a sitting or standing posi-
Normal blood pressure 120 and 80 tion. It is caused by the inability of blood vessels
to compensate quickly to the change in position.
Normal range 100–120 and 60–80 The individual becomes lightheaded and dizzy,
Prehypertension 120–139 or 80–89 and may experience blurred vision. The symp-
toms last a few seconds until the blood vessels
Hypertension compensate and more blood is pushed to the
Stage 1 Hypertension 140–159 or 90–99 brain.
Many factors can influence blood pressure
Stage 2 Hypertension 160 or 100
readings. These factors can cause blood pressure
Legend: less than; greater than or equal to to be high or low. Some examples include:
♦ Factors causing changes in readings: force of
pressure is an important indicator of the health the heartbeat, resistance of the arterial sys-
and tone of arterial walls. A normal range for tem, elasticity of the arteries, volume of blood
pulse pressure in adults is 30 to 50 mm Hg. For in the arteries, and position of the patient
example, if the systolic pressure is 120 mm Hg (lying down, sitting, or standing)
and the diastolic pressure is 80 mm Hg, the pulse ♦ Factors that may increase blood pressure:
pressure is 40 mm Hg (120 80 40). The pulse excitement, anxiety, nervous tension, exercise,
pressure should be approximately one third of eating, pain, obesity, smoking, and/or stimu-
the systolic reading. A high pulse pressure can be lant drugs
caused by an increase in blood volume or heart ♦ Factors that may decrease blood pressure: rest
rate, or a decrease in the ability of the arteries to or sleep, depressant drugs, shock, dehydra-
expand. tion, hemorrhage (excessive loss of blood),
Prehypertension is indicated when pressures and fasting (not eating)
are between 120 and 139 mm Hg systolic or 80
and 89 mm Hg diastolic. Prehypertension is a A sphygmomanometer is an instrument
warning that high blood pressure will develop used to measure blood pressure in millimeters of
unless steps are taken to prevent it. Research has mercury (mm Hg). There are three main types of
proven that prehypertension can harden arteries, sphygmomanometers: mercury, aneroid, and
dislodge plaque, and block vessels that nourish electronic. The mercury sphygmomanometer
the heart. Proper nutrition and a regular exercise has a long column of mercury (figure 15-26). Each
program are the main treatments for prehyper- mark on the gauge represents 2 mm Hg. The mer-
tension. cury sphygmomanometer must always be placed
Hypertension, or high blood pressure, is on a flat, level surface or mounted on a wall. If it
indicated when pressures are greater than 140 is calibrated correctly, the level of mercury should
mm Hg systolic and 90 mm Hg diastolic. Com- be at zero when viewed at eye level. Even though
mon causes include stress, anxiety, obesity, high the mercury sphygmomanometer has proven to
salt intake, aging, kidney disease, thyroid defi- be the most accurate instrument for measuring
ciency, and vascular conditions such as arterio- blood pressure, the Occupational Health and
sclerosis. Hypertension is often called a “silent Safety Administration (OSHA) discourages its use
killer” because most individuals do not have any because of the possibility of a mercury spill and
signs or symptoms of the disease. If hypertension contamination. The aneroid sphygmomanome-
is not treated, it can lead to stroke, kidney disease, ter does not have a mercury column (figure
and/or heart disease. 15-27A). However, it is calibrated in mm Hg. Each
Hypotension, or low blood pressure, is indi- line represents 2 mm Hg pressure. When the cuff
cated when pressures are less than 90 mm Hg is deflated, the needle must be on zero (figure
442 CHAPTER 15
FIGURE 15-27B If the needle is not on zero

FIGURE 15-26 The gauge on a mercury sphyg- when the aneroid cuff is deflated, the sphygmoma-
momanometer has a column of mercury. nometer should not be used until it is recalibrated.
Scale with measurements Bulb
Cuff
Control
valve
FIGURE 15-27A The gauge on an aneroid sphyg-

momanometer does not contain a column of
mercury. FIGURE 15-28 Electronic sphygmomanometers
provide a digital display of blood pressure and pulse
15-27B). If the needle is not on zero, the sphyg- readings.
momanometer should not be used until it is reca-
librated. Electronic sphygmomanometers are 5 minutes before blood pressure is taken. The
used in many health care facilities (figure 15-28). AHA also recommends that two separate read-
Blood pressure and pulse readings are shown on ings be taken and averaged, with a minimum wait
a digital display after a cuff is placed on the of 30 seconds between readings.
patient. The size and placement of the sphygmoma-
In order to obtain accurate blood pressure nometer cuff is also important (figure 15-29). The
readings, it is important to observe several fac- cuff contains a rubber bladder that fills with air to
tors. The American Heart Association (AHA) rec- apply pressure to the arteries. Cuffs that are too
ommends that the patient sit quietly for at least wide or too narrow give inaccurate readings. A
Vital Signs 443
surface. The area of the arm covered by the cuff

should be at heart level. The arm must be free of
any constrictive clothing. The deflated cuff should
be placed on the arm with the center of the blad-
der in the cuff directly over the brachial artery,
and the lower edge of the cuff 1 to 11⁄2 inches
above the antecubital area (bend of the elbow).
A final point relating to accuracy is placement
of the stethoscope bell/diaphragm. The bell/dia-
phragm should be placed directly over the bra-
chial artery at the antecubital area and held
securely but with as little pressure as possible.
For a health care worker, a major responsi-
FIGURE 15-29 It is important to use the correct bility is accuracy in taking and recording
size cuff because cuffs that are too wide or too blood pressure. You should not discuss the read-
narrow will result in inaccurate readings. ing with the patient. This is the responsibility of
the physician because the information may cause
cuff that is too small will give an artificially high a personal reaction that can affect the treatment.
reading; if it is too large it will give an artificially Only the physician should determine whether an
low reading. To ensure the greatest degree of abnormal blood pressure is an indication for
accuracy, the width of the cuff should be approxi- treatment.
mately 40 percent of the circumference (distance
around) of the patient’s upper arm. The length of STUDENT: Go to the workbook and complete
the bladder should be approximately 80 percent the assignment sheets for 15:7, Measuring and
of the circumference of the patient’s upper arm. Recording Blood Pressure, Reading a Mercury
The patient should be seated or lying comfort- Sphygmomanometer, and Reading an Aneroid
ably and have the forearm supported on a flat Sphygmomanometer. Then return and continue
with the procedure.
PROCEDURE 15:7
NOTE: If possible, allow the patient to
Measuring and sit quietly for 5 minutes before taking
Recording Blood the blood pressure.
Pressure NOTE: Reassure the patient as needed.
Nervous tension and excitement can
Equipment and Supplies alter or elevate blood pressure.
4. Roll up the patient’s sleeve to approxi-
Stethoscope, sphygmomanometer, alcohol
mately 5 inches above the elbow. Posi-
swab or disinfectant, paper, pencil/pen
tion the arm so that it is supported,
comfortable, and close to the level of
Procedure the heart. The palm should be up.
1. Assemble equipment. Use an alcohol NOTE: If the sleeve constricts the arm,
swab or disinfectant to clean the remove the garment. The arm must be
earpieces and bell/diaphragm of the bare and unconstricted for an accurate
stethoscope. reading.
2. Wash hands. 5. Wrap the deflated cuff around the upper
arm 1 to inches above the elbow and
over the brachial artery. The center of
444 CHAPTER 15
PROCEDURE 15:7
the bladder inside the cuff should be
over the brachial artery.
CAUTION: Do not pull the cuff too tight.
The cuff should be smooth and even.
6. Determine the palpatory systolic pres-
sure (figure 15-30A). To do this, find the
radial pulse and keep your fingers on it.
Inflate the cuff until the radial pulse dis-
appears. Inflate the cuff 30 mm Hg
above this point. Slowly release the pres-
sure on the cuff while watching the
gauge. When the pulse is felt again, note
the reading on the gauge. This is the pal-
patory systolic pressure.
7. Deflate the cuff completely. Ask the
patient to raise the arm and flex the fin-
gers to promote blood flow. Wait 30–60
seconds to allow blood flow to resume
completely.
8. Use your fingertips to locate the brachial
artery (figure 15-30B). The brachial FIGURE 15-30B Locate the brachial artery
on the inner part of the arm at the antecubital
space.
artery is located on the inner part of the
arm at the antecubital space (area where
the elbow bends). Place the stethoscope
over the artery (figure 15-30C). Put the
earpieces in your ears.
NOTE: Earpieces should be pointed for-
ward.
9. Check to make sure the tubings are sep-
arate and not tangled together.
10. Gently close the valve on the rubber
bulb by turning it in a clockwise direc-
tion. Inflate the cuff to 30 mm Hg above
the palpatory systolic pressure.
NOTE: Make sure the sphygmomanom-
eter gauge is at eye level.
11. Open the bulb valve slowly and let the
air escape gradually at a rate of 2–3 mm
Hg per second (or per heartbeat if the
heart rate is very slow).
FIGURE 15-30A Determine the palpatory
systolic pressure by checking the radial pulse NOTE: Deflating the cuff too rapidly will
as you inflate the cuff. cause an inaccurate reading.
Vital Signs 445
PROCEDURE 15:7
14. Continue to listen for sounds for 10–20
mm Hg below the last sound. If no fur-
ther sounds are heard, rapidly deflate
the cuff.
15. If you need to repeat the procedure to
recheck your reading, completely deflate
the cuff, wait 1 minute, and repeat the
procedure. Ask the patient to raise the
arm and flex the fingers to promote
blood flow.
CAUTION: If you cannot obtain a read-
ing, report to your supervisor promptly.
16. Record the time and your reading. The
reading is written as a fraction, with sys-
tolic over diastolic. For example, BP
124/72 (or 124/80/72 if the change in
sound is noted).
17. Remove the cuff. Expel any remaining
air by squeezing the cuff. Use alcohol or
a disinfectant to clean the stethoscope
FIGURE 15-30C Place the stethoscope over earpieces and diaphragm/bell. Replace
the brachial artery as you listen for the blood all equipment.
pressure sounds. 18. Check patient for safety and comfort
before leaving.
19. Wash hands.
12. When the first sound is heard, note the
reading on the manometer. This is the 20. Record all required information on the
systolic pressure. patient’s chart or agency form, for exam-
ple, date, time, BP 126/74, your signature
13. Continue to release the air until there is and title. Report any abnormal readings
an abrupt change of the sound, usually immediately to your supervisor.
soft or muffled. Note the reading on the
manometer. Continue to release the air
until the sound changes again, becom-
ing first faint and then no longer heard.
Note the reading on the manometer. Practice
The point at which the first change in Go to the workbook and use the
sound occurs is the diastolic pressure in evaluation sheet for 15:7, Measuring
children. The diastolic pressure in adults and Recording Blood Pressure, to
is the point at which the sound becomes practice this procedure. When you
very faint or stops. believe you have mastered this skill,
NOTE: If you still hear sound, continue
to the zero mark. Record both readings
(the change of sound and the zero read-
ing). For a systolic of 122 and a contin- Final Checkpoint Using the criteria
ued diastolic of 78, this can be written as listed on the evaluation sheet, your
122/78/0. instructor will grade your performance.
446 CHAPTER 15

An artificial heart that eliminates the need for heart transplants?
Artificial hearts have been in use for many years. They are used to keep a patient alive
until a heart transplant can be found. The first artificial heart was used on Barney Clark, a
Seattle dentist, in 1982. It was implanted by Dr. William DeVries. This heart, the Jarvik-7, was
connected to an electrical generator the size of a refrigerator. Wires connected the heart
with the generator. Barney Clark lived for 112 days connected to this device.
Now researchers have developed a new type of artificial heart. By using miniaturized
electronics and high-capacity lithium batteries, scientists have created a heart that allows a
patient to wear a battery pack on his or her waist. Electrical energy passes through the
patient’s skin to power the implanted heart. This allows the patient to resume many normal
daily activities. The patient is no longer attached by wires to a power source. Patients have
lived for many months with this type of heart while waiting for a suitable transplant.
Researchers are now working on an artificial heart that will work with or in place of a
patient’s damaged heart. This heart will have computerized intelligence to understand when
additional blood is needed by the body. It will be able to respond to the demands of the
body, and increase or decrease the heart rate as needed. It will be created from materials
that will not cause a rejection reaction in the body. And finally, it will last for many years.
CHAPTER 15 SUMMARY Blood pressure is the force exerted by the

blood against the arterial walls when the heart
contracts or relaxes. Two measurements are
Vital signs are important indicators of health noted: systolic and diastolic. An abnormal blood
states of the body. The four main vital signs are pressure can indicate disease.
temperature, pulse, respiration, and blood pres- Vital signs are major indications of body
sure. function. The health care worker must use pre-
Temperature is a measurement of the bal- cise methods to measure vital signs so results
ance between heat lost and heat produced by are as accurate as possible. A thorough under-
the body. It can be measured orally, rectally, standing of vital signs and what they indicate
aurally (by way of the ear), temporally, and be- will allow the health care worker to be alert to
tween folds of skin. An abnormal body tempera- any abnormalities so they can be immediately
ture can indicate disease. reported to the correct individual.
Pulse is the pressure of the blood felt against
the wall of an artery as the heart contracts or
beats. Pulse can be measured at various body
sites, but the most common site is the radial INTERNET SEARCHES
pulse, which is at the wrist. The rate, rhythm,
and volume (strength) should be noted each Use the suggested search engines in Chapter 12:4
time a pulse is taken. An apical pulse is taken of this textbook to search the Internet for addi-
with a stethoscope at the apex of the heart. The tional information on the following topics:
stethoscope is used to listen to the heartbeat. 1. Organization: find the American Heart Asso-
Apical pulse is frequently taken on infants and ciation Web site to obtain information on the
small children with rapid pulse rates. heart, pulse, arrhythmias, and blood pressure
Respiration refers to the breathing pro-
2. Vital signs: research body temperature, pulse,
cess. Each respiration consists of an inspiration
respiration, blood pressure, and apical pulse
(breathing in) and an expiration (breathing out).
The rate, rhythm, and character, or type, of res- 3. Temperature scales: research Celcius (Centi-
pirations should always be noted. grade) versus Fahrenheit temperatures: try to
Vital Signs 447
locate conversion charts that can be used to 3. What three (3) factors must be noted about
compare the two scales every pulse?
4. Diseases: research hypothermia, fever or 4. Why is an apical pulse taken?
pyrexia, hypertension, hypotension, and heart
5. What is the pulse deficit if an apical pulse is
arrhythmias.
112 and the radial pulse is 88?
6. Differentiate between hypertension and
REVIEW QUESTIONS hypotension, and list the basic causes of each.
7. How does systolic pressure differ from diastolic
1. List the four (4) main vital signs. pressure? What are the normal ranges for each?
2. State the normal value or range for an adult for 8. Define each of the following:
each of the following: a. bradycardia
a. oral temperature b. arrhythmia
b. rectal or temporal temperature c. dyspnea
c. axillary or groin temperature d. tachypnea
d. pulse e. rales
e. respiration
CHAPTER 16 First Aid
Chapter Objectives
Observe Standard
Precautions
◆ Demonstrate cardiopulmonary resuscitation
for one-person rescue, two-person rescue,
infants, children, and obstructed-airway
Instructor’s Check—Call victims
◆ Describe first aid for
—bleeding and wounds
Safety—Proceed with —shock
Caution —poisoning
—burns
—heat exposure
on Federal Law —cold exposure
—bone and joint injuries, including fractures
—specific injuries to the eyes, head, nose, ears,
Math Skill chest, abdomen, and genital organs
—sudden illness including heart attack, stroke,
fainting, convulsions, and diabetic reactions
◆ Apply dressings and bandages, observing all
safety precautions and using the circular,
Science Skill spiral, figure-eight, and recurrent, or finger
wrap
Technology
First Aid 449
KEY TERMS
abrasion (ahⴖ-brayⴕ-shun) diaphoresis hypothermia
amputation (dyⴖ-ah-feh-reeⴕ-sis) incision
avulsion (ayⴖ-vulⴕ-shun) dislocation infection
bandages dressing insulin shock
burn fainting laceration
cardiopulmonary first aid poisoning
resuscitation (carⴕ-dee-oh- fracture puncture
pullⴕ-meh-nah-ree reeⴖ- frostbite shock
suh-sih-tayⴕ-shun) heart attack sprain
cerebrovascular accident heat cramps strain
(seh-reeⴕ-bro-vassⴖ-ku-lehr heat exhaustion triage (treeⴕ-ahj)
axⴕ-ih-dent)
heat stroke wound
convulsion
hemorrhage
diabetic coma
oughly. Always have a reason for anything you do.

16:1 INFORMATION The treatment you provide will vary depending
on the type of injury or illness, the environment,
Providing First Aid others present, equipment or supplies on hand,
and the availability of medical help. Therefore, it
INTRODUCTION is important for you to think about all these fac-
tors and determine what action is necessary.
In every health care career you may have experi- The first step of first aid is to recognize that
ences that require a knowledge of first aid. This an emergency exists. Many senses can alert you
section provides basic guidelines for all the first to an emergency. Listen for unusual sounds such
aid topics discussed in the remaining sections of as screams, calls for help, breaking glass, screech-
this unit. All students are strongly encouraged to ing tires, or changes in machinery or equipment
take the First Aid Certification Course through noises. Look for unusual sights such as an empty
their local Red Cross divisions to become profi- medicine container, damaged electrical wires, a
cient in providing first aid. stalled car, smoke or fire, a person lying motion-
First aid is not full and complete treatment. less, blood, or spilled chemicals. Note any
Rather, first aid is best defined as “immediate unusual, unfamiliar, or strange odors such as
care that is given to the victim of an injury or ill- those of chemicals, natural gas, or pungent fumes.
ness to minimize the effect of the injury or illness Watch for unusual appearances or behaviors in
until experts can take over.” Application of cor- others such as difficulty in breathing, clutching of
rect first aid can often mean the difference the chest or throat, abnormal skin colors, slurred
between life and death, or recovery versus per- or confused speech, unexplained confusion or
manent disability. In addition, by knowing the drowsiness, excessive perspiration, signs of pain,
proper first aid measures, you can help yourself and any symptoms of distress. Sometimes, signs
and others in a time of emergency. of an emergency are clearly evident. An example
is an automobile accident with victims in cars or
BASIC PRINCIPLES on the street. Other times, signs are less obvious
and require an alert individual to note that some-
OF FIRST AID thing is different or wrong. An empty medicine
container and a small child with slurred speech,
In any situation where first aid treatment is for example, are less obvious signs.
necessary, it is essential that you remain After determining that an emergency exists,
calm. Avoid panic. Evaluate the situation thor- the next step is to take appropriate action to
450 CHAPTER 16
help the victim or victims. Check the scene and scenes of accidents, so avoid any unnecessary
make sure it is safe to approach. A quick glance at movement.
the area can provide information on what has In an emergency, it is essential to call the
occurred, dangers present, number of people emergency medical services (EMS) as soon
involved, and other important factors. If live elec- as possible (figure 16-2). The time factor is criti-
trical wires are lying on the ground around an cal. Early access to the EMS system and advanced
accident victim, for example, a rescuer could be medical care increases the victim’s chance of sur-
electrocuted while trying to assist the victim. An vival. Use a telephone, cellular phone, or CB radio
infant thrown from a car during an automobile to contact the police, ambulance or rescue squad,
accident may be overlooked. A rescuer who fire department, utility company, or other re-
pauses briefly to assess the situation will avoid sources. In most areas of the country, the emer-
such dangerous pitfalls and provide more effi- gency number 911 can be used to contact any of
cient care. If the scene is not safe, call for medical the emergency medical services. Sometimes, it
help. Do not endanger your own life or the lives of may be necessary to instruct others to contact
other bystanders. Allow professionals to handle authorities while you are giving first aid. Make
fires, dangerous chemicals, damaged electrical sure that complete, accurate information is given
wires, and other life-threatening situations. to the correct authority. Describe the situation,
If the scene appears safe, approach the vic- actions taken, exact location, telephone number
tim. Determine whether the victim is conscious from which you are calling, assistance required,
(figure 16-1). If the victim shows no sign of con- number of people involved, and the condition of
sciousness, tap him gently and call to him. If the the victim(s). Do not hang up the receiver or end
victim shows signs of consciousness, try to find the CB radio call until the other party has all the
out what happened and what is wrong. Never necessary information. If you are alone, call EMS
move an injured victim unless the victim is in a immediately before providing any care to:
dangerous area such as an area filled with fire
♦ an unconscious adult
and/or smoke, flood waters, or carbon monoxide
or poisonous fumes, or one with dangerous traf- ♦ an unconscious child who has reached
fic, where vehicles cannot be stopped. If it is nec- puberty
essary to move the victim, do so as quickly and ♦ an unconscious infant or child with a high risk
carefully as possible. Victims have been injured for heart problems
more severely by improper movement at the ♦ any victim for whom you witness a sudden
cardiac arrest
If you are alone, shout for help and start cardio-
Are you pulmonary resuscitation (CPR) if needed for:
okay?
FIGURE 16-1 Determine whether the victim is

conscious by gently tapping and by calling to him or FIGURE 16-2 Call for emergency medical ser-
her. vices (EMS) as soon as possible.
First Aid 451
♦ an unconscious infant or child 1 year of age to scious, breathing, and able to talk, reassure the
puberty victim and try to determine what has happened.
Examine the victim thoroughly. Always have a
♦ any victim of submersion or near drowning sound reason for anything you do. Examples
♦ any victim with cardiac arrest caused by a include:
drug overdose or trauma
♦ Ask the victim about pain or discomfort
If no one arrives to call EMS, continue providing ♦ Check the victim for other types of injuries
care by giving five cycles of CPR (approximately 2 such as fractures (broken bones), burns, shock,
minutes). Then go to the nearest telephone, call and specific injuries
for EMS, and return immediately to the victim.
After calling for help, provide care to the vic- ♦ Note any abnormal signs or symptoms
tim. If possible, obtain the victim’s permission ♦ Check vital signs
before providing any care. Introduce yourself and ♦ Note the temperature, color, and moistness of
ask if you can help. If the victim can respond, he the skin
or she should give you permission before you
provide care. If the victim is a child or minor, and ♦ Check and compare the pupils of the eyes
a parent is present, obtain permission from the ♦ Look for fluids or blood draining from the
parent. If the victim is unconscious, confused, or mouth, nose, or ears
seriously ill and unable to consent to care, and no ♦ Gently examine the body for cuts, bruises,
other relative is available to give permission, you swelling, and painful areas
can assume that you have permission. It is impor-
tant to remember that every individual has the Report any abnormalities noted to emer-
right to refuse care. If a person refuses to give gency medical services when they arrive at the
consent for care, do not proceed. If possible, have scene.
someone witness the refusal of care. If a life- Obtain as much information regarding the
threatening emergency exists, call EMS, alert accident, injury, or illness as possible. This infor-
them to the situation, and allow the professionals mation can then be given to the correct authori-
to take over. ties. Information can be obtained from the victim,
At times it may be necessary to triage the other persons present, or by examination of items
situation. Triage is a method of prioritizing treat- present at the scene. Emergency medical identi-
ment. If a victim has more than one injury or fication contained in a bracelet, necklace, medi-
illness, the most severe injury or illness must be cal card, or Vial-of-Life is an important source of
treated first. If two or more people are involved, information. Empty medicine containers, bottles
triage also determines which person is treated of chemicals or solutions, or similar items also
first. Life-threatening emergencies must be can reveal important information. Be alert to all
treated first. Examples include: such sources of information. Use this informa-
tion to determine how you may help the victim.
♦ no breathing or difficulty in breathing
♦ no pulse
♦ severe bleeding SUMMARY
♦ persistent pain in the chest or abdomen
Some general principles of care should be
♦ vomiting or passing blood observed whenever first aid is necessary. Some of
♦ poisoning these principles are:
♦ head, neck, or spine injuries ♦ Obtain qualified assistance as soon as possi-
♦ open chest or abdominal wounds ble. Report all information obtained, observa-
tions noted, treatment given, and other
♦ shock
important facts to the correct authorities. It
♦ severe partial-thickness and all full-thickness may sometimes be necessary to send some-
burns one at the scene to obtain help.
Proper care for these emergencies is described ♦ Avoid any unnecessary movement of the vic-
in the sections that follow. If the victim is con- tim. Keep the victim in a position that will
452 CHAPTER 16
allow for providing the best care for the type of apparent death or unconsciousness). When you
injury or illness. administer CPR, you breathe for the person and
♦ Reassure the victim. A confident, calm atti- circulate the blood. The purpose is to keep oxy-
tude will help relieve the victim’s anxiety. genated blood flowing to the brain and other vital
body organs until the heart and lungs start work-
♦ If the victim is unconscious or vomiting, do ing again, or until medical help is available.
not give him or her anything to eat or drink. It Clinical death occurs when the heart stops
is best to avoid giving a victim anything to eat beating and the victim stops breathing. Biologi-
or drink while providing first aid treatment, cal death refers to the death of the body cells. Bio-
unless the specific treatment requires that flu- logical death occurs 4–6 minutes after clinical
ids or food be given. death and can result in permanent brain damage,
♦ Protect the victim from cold or chilling, but as well as damage to other vital organs. If CPR can
avoid overheating the victim. be started immediately after clinical death occurs,
♦ Work quickly, but in an organized and efficient the victim may be revived.
manner.
♦ Do not make a diagnosis or discuss the victim’s ABCDs OF CPR
condition with observers at the scene. It is
essential to maintain confidentiality and pro- Cardiopulmonary resuscitation is as simple as
tect the victim’s right to privacy while provid- ABCD. In fact, the ABCDs serve as guides to life-
ing treatment. saving techniques for persons who have stopped
♦ Make every attempt to avoid further injury. breathing and have no pulse.
♦ A stands for airway. To open the victim’s air-
CAUTION: Provide only the treatment that way, use the head-tilt/chin-lift method (figure
you are qualified to provide. 16-3). Put one hand on the victim’s forehead
and put the fingertips of the other hand under
STUDENT: Go to the workbook and complete the bony part of the jaw, near the chin. Tilt the
the assignment sheet for 16:1, Providing First Aid. head back without closing the victim’s mouth.
This action prevents the tongue from falling
back and blocking the air passage. If the vic-
16:2 INFORMATION
Performing Cardiopulmonary
Resuscitation
INTRODUCTION
At some time in your life, you may find an
unconscious victim who is not breathing.
This is an emergency situation. Correct action
can save a life. Students are strongly encouraged
to take certification courses in cardiopulmonary
resuscitation (CPR) offered by the American Red
Cross and American Heart Association. This sec-
tion provides the basic facts about CPR for health
care providers according to the 2005 American
Heart Association standards. The information
provided is not intended to take the place of an
approved certification course.
The word parts of cardiopulmonary resus-
citation provide a fairly clear description of the
procedure: cardio (the heart) plus pulmonary FIGURE 16-3 Open the airway by using the head-
(the lungs) plus resuscitation (to remove from tilt/chin-lift method.
First Aid 453
tim has a suspected neck or upper spinal cord ♦ C stands for circulation. By applying pressure
injury, try to open the airway by lifting the to a certain area of the sternum (breastbone),
chin without tilting the head back. If it is dif- the heart is compressed between the sternum
ficult to keep the jaw lifted with one hand, use and vertebral column. Blood is squeezed out
a jaw-thrust maneuver to open the airway. of the heart and into the blood vessels. In this
Assume a position at the victim’s head and rest way, oxygen is supplied to body cells.
your elbows on the surface on which the vic-
tim is lying. Grasp the angles of the victim’s
♦ D stands for defibrillation. One of the most
common causes of cardiac arrest is ventricu-
lower jaw by positioning one hand on each
lar fibrillation, an arrhythmia, or abnormal
side. Lift with both hands to move the lower
electrical conduction pattern in the heart.
jaw forward, making every attempt to avoid
When the heart is fibrillating, it does not pump
excessive backward tilting or side-to-side
blood effectively. A defibrillator is a machine
movement of the head.
that delivers an electric shock to the heart to
♦ B stands for breathing. Breathing means that try to restore the normal electrical pattern and
you breathe into the victim’s mouth or nose to rhythm. Automated external defibrillators
supply needed oxygen or provide ventilations. (AEDs) are now available for use by trained
To avoid loss of air when providing mouth-to- first responders, emergency medical techni-
mouth breathing, it is important to pinch the cians, and even citizens (figure 16-5). After
victim’s nose shut and make a tight seal around electrode pads are positioned on the victim’s
the victim’s mouth with your mouth. Each chest, the AED determines the heart rhythm,
breath should take about 1 second and the recognizes abnormal rhythms that may
chest should rise. Rapid or forceful breaths respond to defibrillation, and sounds an audi-
should be avoided because they can force air ble or visual warning telling the operator to
into the esophagus and stomach, causing gas- push a “shock” button. Some AEDs are fully
tric distension. This can cause serious compli- automatic and even administer the shock.
cations such as vomiting, aspiration of fluids Anytime a shock is administered with an AED,
into the lungs, and even pneumonia. it is essential to make sure no one is touching
CAUTION: Follow standard precautions. If the victim. The rescuer should state “Clear the
possible, use a CPR pocket face mask with a victim,” and look carefully to make sure no
one-way valve to provide a barrier and pre- one is in contact with the victim before push-
vent the transmission of disease (figure ing the shock button. Serious injuries, such as
16-4). Special training is required for the use cardiac arrest, could occur in other rescuers if
of this mask. Other protective barrier face they are shocked by the AED. Newer models of
shields are also available.
FIGURE 16-5 When cardiac arrest occurs, an

FIGURE 16-4 Whenever possible, use a CPR automated external defibrillator (AED) can be used
barrier mask to prevent transmission of disease to analyze the electrical rhythm of the heart and to
while giving respirations. The tubing on the mask apply a shock to try to restore the normal heart
can be connected to an oxygen supply. rhythm.
454 CHAPTER 16
AEDs allow the rescuer to deliver either adult ♦ any victim of submersion or near drowning
or child defibrillator shocks. By using smaller
pediatric electrodes and/or a switch on the
♦ any victim with cardiac arrest caused by a
drug overdose or trauma
AED, the rescuer can deliver a smaller electri-
cal shock. The pediatric dose is recommended If no help arrives to call EMS, administer five
for any child from 1–8 years of age. The adult cycles of CPR (about 2 minutes), and then call
defibrillator dose and adult electrodes should fast for EMS. Return to the victim immediately to
be used for any child 8 years or older. In addi- continue providing care until EMS arrives.
tion, if an AED does not have the option of a After determining that a victim is uncon-
pediatric dosage, the adult dosage and elec- scious, the second step is to check for breathing.
trodes should be used on the child. Currently, Try not to move the victim while you check
there is no recommendation for or against the breathing. If the victim is breathing, leave the vic-
use of AEDs in infants younger than 1 year. tim in the same position and proceed with other
Studies have shown that the sooner defibrilla- needed care. If the victim is not breathing, or you
tion is provided, the greater the chances of are unable to determine whether the victim is
survival are from a cardiac arrest caused by an breathing, position the victim on his or her back.
arrhythmia. However, it is essential to remem- If you must turn the victim, support the victim’s
ber that CPR is used until an AED is available. head and neck, and keep the victim’s body in as
CPR will circulate the blood and prevent bio- straight a line as possible while turning (figure
logical death. 16-6). Then, open the airway by using the head-
tilt/chin-lift or, if a neck or spinal cord injury is
It is important to know and follow the ABCDs
suspected, the jaw-thrust maneuver. This step
in proper sequence while administering CPR.
will sometimes start the victim breathing. To
check for breathing, use a three-point evaluation
BASIC PRINCIPLES for at least 5 but not more than 10 seconds. Look
for chest movement. Listen for breathing through
OF CPR the nose or mouth. Feel for movement of air from
the nose or mouth. If the victim is not breathing,
Extreme care must be taken to evaluate the vic- give two breaths, each breath lasting approxi-
tim’s condition before CPR is started. The first mately 1 second. Make sure the breaths are effec-
step is to determine whether the victim is con- tive by watching for the victim’s chest to rise. Do
scious. Tap the victim gently and ask, “Are you not give breaths too quickly or with too much
OK?” If you know the victim, call the victim by
name and speak loudly. If there is no response
and the victim is unconscious, call for help. The
American Heart Association and the American
Red Cross recommend a “call first, call fast” pri-
ority. If you are alone, call first before providing
any care to:
♦ an unconscious adult
♦ an unconscious child who has reached puberty
as defined by the presence of secondary sex
characteristics
♦ an unconscious infant or child with a high risk
for heart problems
♦ any victim for whom you witness a sudden
cardiac arrest
If you are alone, shout for help, and start CPR if
needed for:
FIGURE 16-6 To turn a victim, support the
♦ an unconscious infant or child from 1 year of victim’s head and neck, and keep the victim’s body
age to puberty in as straight a line as possible.
First Aid 455
force because this can cause gastric distension.

Pause very briefly between breaths to allow air
flow back out of the lungs. In addition, take a
breath between the two breaths to increase the
oxygen content of the rescue breath.
After giving two breaths, check the carotid
pulse in the neck to determine whether cardiac x
compression is needed. Take at least 5 but no
more than 10 seconds to determine whether the
pulse is absent before starting compressions.
CAUTION: Cardiac compressions are not
given if the pulse can be felt. If a person has
stopped breathing but still has a pulse, it
may be necessary to give only pulmonary
respiration.
Correct hand placement is essential before
performing chest compressions. For adults, the
hand is placed on the lower half of the sternum FIGURE 16-7B Place the heel of your opposite
between the nipples. While kneeling alongside hand two fingers’ width above the substernal notch.
the victim, find the correct position by using the This should place the hand on the lower half of the
sternum between the nipples.
middle finger of your hand that is closest to the
victim’s feet to follow the ribs up to where the ribs
meet the sternum, at the substernal notch (figure CAUTION: The xiphoid process can be bro-
16-7A). Keep the middle finger on the notch and ken off quite easily and therefore should not
position the index finger above it so two fingers be pressed.
are on the sternum. Then place the heel of your After positioning your hands on the sternum,
opposite hand (the hand closest to the victim’s straighten your arms and align your shoulders
head) on the sternum, next to the index finger directly over your hands. To give compressions,
(figure 16-7B). Measuring in this manner mini- push straight down on the victim’s sternum with
mizes the danger of applying pressure to the tip a hard, fast motion. On an adult, the sternum
of the sternum, called the xiphoid process. should be compressed 11⁄2 to 2 inches. After each
compression, allow the chest to recoil completely.
Deliver compressions at a rate of 100 compres-
sions per minute. Proper administration of com-
pressions will produce adequate blood flow and
improve the victim’s chances of survival.
CPR FOR ADULTS,

INFANTS, AND
CHILDREN
Cardiopulmonary resuscitation can be performed
on adults, children, and infants. In addition, it
can be done by one person or two persons. Rates
of ventilations and compressions vary according
to the number of persons giving CPR and the age
of the victim.
FIGURE 16-7A To position hands correctly for ♦ One-person adult rescue: For adults, a lone
chest compressions, first use a finger to follow the rescuer should provide 30 compressions fol-
ribs up to where they meet the sternum at the lowed by 2 ventilations, for a cycle ratio of
substernal notch. 30:2. Compressions should be hard, fast, and
456 CHAPTER 16
deep, and given at the rate of approximately

100 per minute. Five 30:2 cycles should be
completed every 2 minutes. The hands should
be positioned correctly on the sternum. The
two hands should be interlaced and only the
heel of the palm should rest on the sternum.
Pressure should be applied straight down to
compress the sternum approximately 11⁄2 to
2 inches, or 3.8 to 5.0 centimeters.
♦ Two-person adult rescue: Two people perform-
ing a rescue on an adult victim allows one
person to give breaths while the second per-
son provides compressions. During the res-
cue, the person giving breaths can check the
effectiveness of the compressions by feeling
for a carotid pulse while chest compressions
are administered. One rescuer applies the
FIGURE 16-8 Use the brachial pulse site in the
compressions at the rate of 100 per minute. arm to check for a pulse in an infant.
After every 30 compressions, the second res-
cuer provides 2 ventilations. Thus, there is a
30:2 ratio. stands at the infant’s feet and places his or her
♦ Infants: Cardiopulmonary resuscitation for thumbs next to each other on the lower half of
an infant is given to any infant from birth to the sternum just below the nipple line. The
1 year of age. It is different than that for an rescuer then wraps his or her hands around
adult because of the infant’s size. To open the the infant to support the infant’s back with the
airway, use a head-tilt/chin-lift method, but fingers. A ratio of 15 compressions to 2 venti-
the infant’s head should not be tilted as far lations is used by the two rescuers.
back as an adult’s because this can obstruct ♦ Children: Cardiopulmonary resuscitation for
the infant’s airway. Ventilations are given by children depends on the size of the child.
covering both the infant’s nose and mouth; a Health care providers should use child CPR
seal is made by the mouth of the rescuer. methods for any child from 1 year of age to
Breaths are given until the infant’s chest visi- puberty. If a child shows signs of puberty, as
bly rises. Extreme care must be taken to avoid evidenced by secondary sex characteristics,
overinflating the lungs and/or forcing air into adult CPR methods should be used. The initial
the stomach. The brachial pulse site in the steps of CPR for a child are the same steps
arm is used to check pulse (figure 16-8). Com- used in adult CPR, except that the head is not
pressions are given by placing two fingers on tilted as far back when the airway is opened.
the lower half of the sternum just below an The main differences relate to compressions.
imaginary line drawn between the nipples. The heel of one hand (or two hands) is placed
The sternum should be compressed about 1⁄3 on the lower half of the sternum in the same
to 1⁄2 of the depth of the chest. Compressions position used for adult compressions. If only
are given at a rate of 100 per minute. A lone one hand is used, the other hand remains on
rescuer gives 30 compressions followed by 2 the forehead to keep the airway open. The
respirations for a 30:2 ratio. The infant’s back sternum is compressed 1⁄3 to 1⁄2 the depth of
must be supported at all times when giving the chest. Compressions are given at a rate of
compressions. If two rescuers are available to 100 per minute. After each set of 30 compres-
perform CPR on an infant, a two-thumb tech- sions, 2 breaths are given until the chest visibly
nique can be used by one rescuer to perform rises. This provides a 30:2 ratio. Approximately
compressions while the second rescuer gives five cycles of CPR should be completed every
breaths. The rescuer providing compressions 2 minutes.
First Aid 457
♦ If the victim is unconscious and has an

CHOKING VICTIMS obstructed airway, administer adult CPR.
A choking victim has an obstructed airway The only change to the adult CPR method is
(an object blocking the airway). Special mea- that every time the airway is opened to give
sures must be taken to clear this obstruction. breaths, the rescuer should look in the victim’s
mouth for the object. If the object is visible,
♦ If the victim is conscious, coughing, talking or the rescuer should use a C-shaped or hooking
making noise, and/or able to breathe, the air- motion to remove the object. If the object is
way is not completely obstructed. Remain not seen, the rescuer should try to administer
calm and encourage the victim to remain breaths and then continue with chest com-
calm. Encourage the victim to cough hard. pressions.
Coughing is the most effective method of
expelling the object from the airway. ♦ If an infant (birth to 1 year old) has an
obstructed airway, a different sequence of
♦ If the victim is conscious but not able to
steps is used to remove the obstruction. The
talk, make noise, breathe, or cough, the air-
sequence includes five back blows; five chest
way is completely obstructed. The victim
thrusts; a check of the mouth; a finger sweep,
usually grasps his or her throat and appears
if the object is seen; and an attempt to venti-
cyanotic (blue discoloration of the skin) (fig-
late. The sequence, described in detail in Pro-
ure 16-9). Immediate action must be taken to
cedure 16:2F, is repeated until the object is
clear the airway. Abdominal thrusts, as
expelled, ventilations are successful, or other
described in Procedure 16:2E, are given to
qualified medical help arrives.
provide a force of air to push the object out of
the airway. ♦ If a child aged 1 to puberty has an obstructed
airway, the same sequence of steps used for an
adult is followed. A finger sweep of the mouth
is not performed unless the object can be seen
in the mouth.
Once CPR is started, it must be continued

unless one of the following situations occur:
♦ The victim recovers and starts to breathe.

♦ Other qualified help arrives and takes over.
♦ A doctor or other legally qualified person
orders you to discontinue the attempt.
♦ The rescuer is so physically exhausted, CPR

can no longer be continued.
♦ The scene suddenly becomes unsafe.

♦ You are given a legally valid do not resuscitate
(DNR) order.

the assignment sheet for 16:2, Performing Cardio-
FIGURE 16-9 A choking victim usually grasps her pulmonary Resuscitation. Then return and con-
throat and appears cyanotic. tinue with the procedures.
458 CHAPTER 16
PROCEDURE 16:2A
the victim’s jaw, near the chin. Tilt the
Performing CPR— head without closing the victim’s
One-Person Adult mouth.
Rescue NOTE: This action moves the tongue
away from the back of the throat and
Equipment and Supplies prevents the tongue from blocking the
airway.
CPR manikin, alcohol or disinfecting solu-
CAUTION: If the victim has a suspected
tion, gauze sponges
neck or upper spinal cord injury, use a
jaw-thrust maneuver to open the air-
Procedure way. Assume a position on either side of
the patient’s head. Grasp the angles of
CAUTION: Only a CPR training manikin
the victim’s lower jaw by positioning one
(figure 16-10) should be used to practice
hand on each side. Lift with both hands
this procedure. Never practice CPR on
to move the lower jaw forward, making
another person.
every attempt to avoid excessive back-
1. Assemble equipment. Position the man- ward tilting or side-to-side movement
ikin on a firm surface, usually the floor. of the head.
2. Check for consciousness. Shake the “vic- 4. Check for breathing. Put your ear close
tim” by tapping the shoulder. Ask, “Are to the victim’s nose and mouth while
you OK?” If the victim does not respond, looking at the chest. Look, listen, and
activate EMS immediately. Follow the feel for respirations for at least 5 but not
“call first, call fast” priority. Get an AED more than 10 seconds (figure 16-11A).
if available.
5. If the victim is breathing, keep the airway
3. Open the airway. Use the head-tilt/chin- open and obtain medical help. If the vic-
lift method. Place one hand on the victim is not breathing, administer mouth-
tim’s forehead. Place the fingertips of to-mouth resuscitation as follows:
the other hand under the bony part of
a. Keep the airway open.
b. Resting your hand on the victim’s
forehead, use your thumb and fore-
finger to pinch the victim’s nose shut.
FIGURE 16-11A Open the airway and take at

FIGURE 16-10 Use only training manikins least 5 but no more than 10 seconds to look,
while practicing CPR. listen, and feel for breathing.
First Aid 459
PROCEDURE 16:2A
c. Seal the victim’s mouth with your
mouth or position your mouth on the
barrier mask.
d. Give two breaths, each lasting
approximately 1 second until the
chest visibly rises (figure 16-11B).
Pause slightly between breaths. This
allows air to flow out and provides
you with a chance to take a breath
and increase the oxygen level for the
second rescue breath.
e. Watch the chest for movement to be
sure the air is entering the victim’s FIGURE 16-11C Palpate the carotid pulse for
lungs. Avoid overinflating the lungs at least 5 but not more than 10 seconds to
and/or forcing air into the stomach. determine whether the heart is beating.
more than 10 seconds to feel for the
tions. If possible, use a CPR pocket face
pulse (figure 16-11C). At the same time,
mask with a one-way valve to provide a
watch for breathing, signs of circulation,
barrier and prevent the transmission of
and/or movement.
disease.
NOTE: The pulse may be weak, so check
CAUTION: Giving breaths too quickly or
carefully.
with too much force can cause gastric
distention. This can lead to serious com- 7. If the victim has a pulse, continue pro-
plications such as vomiting, aspiration viding mouth-to-mouth resuscitation.
of fluids into the lungs, and pneumonia. Give one breath every 5–6 seconds.
Count, “One, one thousand; two, one
6. Palpate the carotid pulse. Kneeling at
thousand; three, one thousand; four,
the victim’s side, place the fingertips of
one thousand; and breathe,” to obtain
your hand on the victim’s voice box.
the correct timing. Recheck the pulse
Then slide the fingers toward you and
every 2 minutes to make sure the heart
into the groove at the side of the victim’s
is still beating.
neck, where you should find the carotid
pulse. Take at least 5 seconds but not 8. If the victim does not have a pulse, admin-
ister chest compressions as follows:
a. Locate the correct place on the ster-
num. While kneeling alongside the
victim, use the middle finger of your
hand that is closest to the victim’s
feet to follow the ribs up to where the
ribs meet the sternum, at the sub-
sternal notch. Keep the middle finger
on the notch and position the index
finger above it so two fingers are on
the sternum. Then, place the heel of
FIGURE 16-11B If the victim is not breathing, the opposite hand (the one closest to
open the airway and give two breaths. Watch for the victim’s head) on the sternum,
the chest to visibly rise. next to the index finger.
460 CHAPTER 16
PROCEDURE 16:2A
CAUTION: The heel of your hand should f. Allow the chest to recoil or re-expand
be on the lower half of the sternum at completely after each compression.
the nipple line. Keep your hands on the sternum dur-
ing the upstroke (chest relaxation
b. Place your other hand on top of the
period).
hand that is correctly positioned.
Keep your fingers off the victim’s NOTE: When the chest recoils or re-
chest. It may help to interlock your expands completely, this allows more
fingers. blood to refill the heart between com-
pressions.
c. Rise up on your knees so that your
shoulders are directly over the vic- 9. After administering 30 compressions,
tim’s sternum. Lock your elbows and give the victim 2 ventilations, or respira-
keep your arms straight. tions. Avoid excessive body movement
while giving the ventilations. Keep your
NOTE: This position will allow you to
knees in the same position and swing
push straight down on the sternum and
your body upward to give the respira-
compress the heart, which lies between
tions.
the sternum and vertebral column.
NOTE: Make every effort to minimize
d. Push down hard and fast to compress
any interruptions to chest compres-
the chest approximately 11⁄2 to 2
sions. There is no blood flow to the brain
inches, or 3.8 to 5.0 centimeters (fig-
and heart when compressions are not
ure 16-11D). Use a smooth, even
being performed.
motion.
10. Continue the cycles of 30 compressions
e. Administer 30 compressions at the
followed by 2 ventilations until EMS
rate of 100 per minute. Count, “One,
providers take over, an AED arrives, or
two, three,” and so forth, to obtain
the victim recovers.
the correct rate.
11. If an automated external defibrillator
(AED) is available, give five cycles of CPR
and then use the AED. Even though
Upstroke Downstroke
AEDs have different manufacturers and
Effort arm
11/2"- 2" models, they all operate in basically the
(back) same way.
a. Position the AED at the victim’s side
Fulcrum
(hip joints)
next to the rescuer who is using it. If
Piston another person arrives to help, the
(arms)
second person can activate EMS (if
this has not already been done) and
then administer cycles of CPR on the
victim’s other side.
b. Open the case on the AED and turn
on the power control.
Resistance
(lower half NOTE: Some AEDs power on automati-
of sternum) cally when the case is opened.
FIGURE 16-11D Use hard and fast motions c. Expose the victim’s chest and attach
to compress the chest straight down while the chest electrodes to bare skin. If
giving 30 compressions.
First Aid 461
PROCEDURE 16:2A
the chest is covered with sweat or f. Follow the recommendations of the
water, quickly wipe it dry. Choose the AED. If the AED says NO SHOCK,
correct size electrode pad. Use adult resume CPR by giving 30 compres-
size pads for any victim 8 years and sions followed by 2 ventilations.
older. Peel the backing off of the elec-
g. If the AED says SHOCK, make sure
trode pad. Place one pad on the upper
the victim is clear. Loudly state “Clear
right side of the chest, below the clav-
victim,” and look to make sure no
icle (collarbone) and to the right of
one is touching the victim. Push the
the sternum (breastbone). Place the
shock button.
second electrode pad on the left side
of the chest to the left of the nipple CAUTION: If another rescuer is touch-
and a few inches below the axillae ing the victim, the rescuer will also
(armpit). receive the shock. This can cause a seri-
ous injury and/or a cardiac arrest.
d. If necessary, attach the connecting
cables of the electrodes to the elec- h. Begin cycles of CPR by starting with
trode pad and AED. Some types of chest compressions immediately
electrodes are preconnected. after the shock is delivered to the vic-
tim. After 2 minutes of CPR, most
e. Clearly state “Clear the victim.” Look
AEDs will prompt you to reanalyze
carefully to make sure no one is
the rhythm and deliver additional
touching the victim. Push the analyze
shocks if necessary.
control to allow the AED to evaluate
the heart rhythm (figure 16–12). The 12. After you begin CPR, do not stop unless
analysis may take 5–15 seconds. a. the victim recovers
b. help arrives to take over and give CPR
and/or apply an AED
c. a physician or other legally qualified
person orders you to discontinue the
attempt
d. you are so physically exhausted, you
cannot continue
e. the scene suddenly becomes unsafe
f. you are given a legally valid do not
resuscitate (DNR) order
13. After the practice session, use a gauze
pad saturated with 70-percent alcohol
or a 10-percent bleach disinfecting solu-
tion to clean the manikin. Wipe the face
and clean inside the mouth thoroughly.
Saturate a clean gauze pad with the
solution and lay it on the mouth area for
at least 30 seconds. Use another gauze
FIGURE 16-12 “Clear” the victim before pad to wipe the area dry. Follow manu-
pushing the control to allow the automated facturer’s instructions for any additional
external defibrillator (AED) to analyze the cleaning required.
victim’s heart rhythm.
462 CHAPTER 16
PROCEDURE 16:2A
NOTE: A 10-percent bleach solution is
more effective than alcohol. Some man-
ikins have disposable mouthpieces that
are discarded after use. If the mouth- Practice
piece is discarded, the remainder of the Go to the workbook and use the
face should still be disinfected. evaluation sheet for 16:2A,
Performing CPR—One-Person
14. Replace all equipment used. Wash Adult Rescue, to practice this
hands.
Final Checkpoint Using the criteria have mastered this skill, sign the
listed on the evaluation sheet, your sheet and give it to your instructor
instructor will grade your performance. for further action.
PROCEDURE 16:2B
part of the victim’s jaw, near the chin.
Performing CPR— Tilt the victim’s head back without clos-
Two-Person Adult ing the victim’s mouth.
Rescue 5. Check for breathing. Look, listen, and
feel for breathing for at least 5 but not
Equipment and Supplies more than 10 seconds.
6. If the victim is not breathing, give two
CPR manikin, alcohol or disinfecting solu-
breaths, each lasting approximately
tion, gauze sponges
1 second. Watch the chest for movement
to be sure air is entering the victim’s
Procedure lungs. Avoid overinflating the lungs
and/or forcing air into the stomach.
CAUTION: Only a CPR training manikin
should be used to practice this proce- CAUTION: Follow standard precau-
dure. Never practice CPR on another tions. If possible, use a CPR pocket face
person. mask with a one-way valve to provide a
barrier and prevent the transmission of
1. Assemble equipment. Position the man-
disease.
ikin on a firm surface, usually the floor.
7. Feel for the carotid pulse for at least
2. Shake the victim to check for conscious-
5 seconds and not more than 10 sec-
ness. Ask, “Are you OK?”
onds. Watch for signs of breathing, cir-
3. If the victim is unconscious, one rescuer culation, and/or movement.
checks for breathing and begins CPR.
8. If there is no pulse, give chest compres-
The second rescuer activates emergency
sions. Locate the correct hand position
medical services and obtains an AED if
on the sternum. Until the second res-
available.
cuer returns, provide compressions and
4. Use the head-tilt/chin-lift method to respirations as for a one-person rescue.
open the victim’s airway. Place one hand Give 30 hard, fast, and deep compres-
on the victim’s forehead. Place the fin- sions followed by 2 respirations.
gertips of the other hand under the bony
First Aid 463
PROCEDURE 16:2B
9. When the second rescuer returns after
calling for help, the first rescuer should
complete the cycle of 30 compressions
and 2 respirations.
10. The second rescuer should get into posi-
tion for compressions and locate the
correct hand placement while the first
rescuer is giving the two breaths. The
second rescuer should begin compres-
sions at the rate of 100 per minute (fig-
ure 16-13A). The second rescuer should
count out loud, “One, two, three, four,
five . . .” After each set of 30 compres-
sions, the second rescuer should pause
very briefly to allow the first rescuer to
give 2 breaths. Rescue then continues
with 2 breaths after each 30 compres-
FIGURE 16-13B Rescuers should change
positions after every five cycles of CPR
sions.
because the person doing compressions gets
11. After every five cycles of CPR (approxi- tired, and compressions are not as effective.
mately 2 minutes) the rescuers should
change positions. The person giving
for compressions (figure 16-13B). The
compressions can provide a clear signal
compressor should move to the head
to change positions, such as, “Change,
and open the airway. The new compres-
two, three, four. . . .” The compressor
sor should then give 30 hard, fast, and
should complete a cycle of 30 compres-
deep compressions at the rate of 100 per
sions. The ventilator should give 2 breaths
minute. The rescue should continue with
at the end of the 30 compressions. The
2 ventilations after each 30 compres-
ventilator should then move to the chest
sions.
and locate the correct hand placement
12. If an AED is available, one rescuer should
set up the AED while the other rescuer is
giving cycles of CPR. When the AED is
ready to analyze the heart rhythm, the
rescuer operating the AED must make
sure the other rescuer is clear of the vic-
tim. The steps for using the AED are dis-
cussed in detail in step 11 of Procedure
16:2A.
13. The rescuers should continue CPR until
qualified medical help arrives, the vic-
tim recovers, a doctor or other legally
qualified person orders CPR discontin-
ued, the scene suddenly becomes unsafe,
or they are presented with a legally valid
do not resuscitate (DNR) order.
FIGURE 16-13A In a two-person rescue, two 14. After the practice session, use a gauze
breaths are given after every 30 compressions. pad saturated with 70-percent alcohol
464 CHAPTER 16
PROCEDURE 16:2B
Saturate a clean gauze pad with the Practice
solution and lay it on the mouth area for Go to the workbook and use the
at least 30 seconds. Use another gauze evaluation sheet for 16:2B,
pad to wipe the area dry. Follow manu- Performing CPR—Two-Person
facturer’s instructions for any additional Adult Rescue, to practice this
cleaning required. procedure. When you believe you
for further action.
are discarded after use. If the mouth-
piece is discarded, the remainder of the
face should still be disinfected.
15. Replace all equipment used. Wash listed on the evaluation sheet, your
hands. instructor will grade your performance.
PROCEDURE 16:2C
no one arrives to call EMS, stop CPR
Performing CPR after five cycles (approximately 2 min-
on Infants utes) to telephone for medical assis-
tance. Resume CPR as quickly as
Equipment and Supplies possible.
NOTE: If the infant is known to have a
CPR infant manikin, alcohol or disinfecting
high risk for heart problems or a sudden
solution, gauze pads
collapse was witnessed, activate EMS
and then begin CPR.
Procedure
4. Use the head-tilt/chin-lift method to
CAUTION: Only a CPR training manikin open the infant’s airway. Tip the head
should be used to practice this proce- back gently, taking care not to tip it as
dure. Never practice CPR on a human far back as you would an adult’s head.
infant. CAUTION: Tipping the head too far will
1. Assemble equipment. cause an obstruction of the infant’s air-
way.
2. Gently shake the infant or tap the infant’s
foot (for reflex action) to determine con- 5. Look, listen, and feel for breathing (fig-
sciousness. Call to the infant. ure 16-14A). Check for at least 5 but not
more than 10 seconds.
NOTE: For CPR techniques, infants are
usually considered to be under 1 year 6. If there is no breathing, give two breaths,
old. each breath lasting approximately 1 sec-
ond. Cover the infant’s nose and mouth
3. If the infant is unconscious, call aloud
with your mouth. Breathe until the chest
for help, and begin the steps of CPR. If
First Aid 465
PROCEDURE 16:2C
for at least 5 but not more than 10 sec-
onds.
8. If a pulse is present, continue providing
ventilations by giving the infant one
ventilation every 3 seconds (approxi-
mately 20 breaths per minute). Recheck
the pulse every 2 minutes.
9. If no pulse is present or if the heart rate is
below 60 beats per minute with signs of
poor circulation such as cyanosis, admin-
ister cardiac compressions. Locate the
correct position for compressions by
drawing an imaginary line between the
FIGURE 16-14A Look, listen, and feel for nipples. Place two fingers on the ster-
breathing for at least 5 but not more than 10 num just below this imaginary line. Give
seconds. compressions at the rate of 100 per min-
ute (figure 16-14C). Make sure the infant
rises visibly during each ventilation. is on a firm surface, or use one hand to
Allow for chest deflation after each support the infant’s back while admin-
breath. istering compressions. Press hard, fast,
7. Check the pulse over the brachial artery. and deep enough to compress the
Place your fingertips on the inside of the infant’s chest 1⁄3 to 1⁄2 the depth of the
upper arm and halfway between the chest. Give 30 compressions at the rate
elbow and shoulder (figure 16-14B). Put of 100 per minute. Allow the chest to
your thumb on the posterior (outside) recoil or re-expand completely between
of the arm. Squeeze your fingers gently compressions.
toward your thumb. Feel for the pulse
FIGURE 16-14C Use two fingers to give hard

FIGURE 16-14B Check the pulse at the and fast compressions to the infant, at a rate of
brachial artery in the upper arm. 100 compressions per minute.
466 CHAPTER 16
PROCEDURE 16:2C
10. After every 30 compressions, give 2 with a legally valid do not resuscitate
breaths until the chest rises visibly. (DNR) order (very rare for infants).
11. Continue the cycle of 30 compressions 14. After the practice session, use a gauze
followed by 2 ventilations. To establish pad saturated with 70-percent alcohol
the correct rate, count, “One, two, three, or a 10-percent bleach disinfecting solu-
four, five.” tion to clean the manikin. Wipe the face
12. If a second rescuer arrives to assist, the
second rescuer should activate EMS if
this has not been done. Then both res-
cuers can perform CPR on the infant.
pad to wipe the area dry. Follow manu-
a. The first rescuer should finish a cycle facturer’s instructions for specific clean-
of 30 compressions followed by 2 res- ing.
pirations.
NOTE: The 10-percent bleach solution
b. The second rescuer should stand at is more effective than alcohol. Some
the infant’s feet and place his or her manikins have disposable mouthpieces
thumbs next to each other on the that are discarded after use. If the
lower half of the sternum just below mouthpiece is discarded, the remainder
the nipple line. The rescuer then of the face should still be disinfected.
wraps his or her hands around the
15. Replace all equipment used. Wash
infant to support the infant’s back
hands.
with the fingers, and uses the thumbs
to administer 15 compressions.
c. After 15 compressions, the person
giving compressions pauses very
briefly so the other rescuer can give 2
ventilations.
Practice
NOTE: The ratio of compressions to evaluation sheet for 16:2C,
ventilations is 15:2 for a two-person res- Performing CPR on Infants to
cue on an infant. practice this procedure. When you
d. The rescuers should switch positions believe you have mastered this skill,
after every six to eight cycles (approx- sign the sheet and give it to your
imately 2 minutes) of CPR. instructor for further action.
13. The rescuers should continue the cycles
of CPR until qualified medical help
arrives, the infant recovers, a doctor or Final Checkpoint Using the criteria
other legally qualified person orders listed on the evaluation sheet, your
CPR discontinued, or they are presented instructor will grade your performance.
First Aid 467
PROCEDURE 16:2D
nose and cover the child’s mouth with
Performing CPR your mouth. Breathe until the chest rises
on Children visibly during each ventilation. Allow for
chest deflation after each breath.
Equipment and Supplies 7. Check the pulse at the carotid pulse site.
Feel for the pulse for at least 5 but not
CPR child manikin, alcohol or disinfecting
solution, gauze pads
8. If a pulse is present, continue providing
Procedure ventilations by giving the child one ven-
tilation every 3 seconds (approximately
CAUTION: Only a CPR training manikin 20 breaths per minute). Recheck the
should be used to practice this proce- pulse every 2 minutes.
dure. Never practice CPR on a human 9. If no pulse is present or if the heart rate is
child. below 60 beats per minute with signs of
1. Assemble equipment. poor circulation such as cyanosis, admin-
ister cardiac compressions. Place the
2. Gently shake the child to determine
heel of one hand on the lower half of the
consciousness. Call to the child.
sternum just below a line drawn between
NOTE: Health care providers should use the nipples or in the same position used
child CPR techniques on any child from for adult CPR. Keep the other hand on
1 year of age to puberty, as evidenced by the child’s forehead (figure 16-15). If the
the development of secondary sex char- child is larger, two hands can be posi-
acteristics.
3. If the child is unconscious, call aloud for
help, and begin the steps of CPR. If no
one arrives to call EMS, stop CPR after
five cycles (approximately 2 minutes) to
telephone for medical assistance and
obtain an AED if available. Resume CPR
as quickly as possible.
NOTE: If the child is known to have a
high risk for heart problems or a sudden
collapse was witnessed, activate EMS
first and then begin CPR.
4. Use the head-tilt/chin-lift method to
open the child’s airway. Tip the head
back gently, taking care not to tip it as
far back as you would an adult’s head.
5. Look, listen, and feel for breathing.
Check for at least 5 but not more than 10
seconds.
6. If there is no breathing, give two breaths,
each breath lasting approximately 1 sec- FIGURE 16-15 Use one hand to give chest
ond. Cover the child’s nose and mouth compressions to a child. Keep the other hand
with your mouth, or pinch the child’s on the child’s forehead.
468 CHAPTER 16
PROCEDURE 16:2D
tioned on the chest for compressions. tim. The steps for using the AED are dis-
Give compressions at the rate of 100 per cussed in detail in step 11 of Procedure
minute. Make sure the child is on a firm 16:2A.
surface, or use one hand to support the
CAUTION: Adult electrode pads should
child’s back while administering com-
be used on any child 8 years or older.
pressions. Press hard, fast, and deep
Child or pediatric electrodes are used
enough to compress the child’s chest 1⁄3
only on children from 1–8 years of age.
to 1⁄2 the depth of the chest. Give 30 com-
pressions at the rate of 100 per minute. 14. The rescuers should continue the cycles
Allow the chest to recoil or re-expand of CPR until qualified medical help arrives,
completely between compressions. the child recovers, a doctor or other legally
qualified person orders CPR discontin-
10. After every 30 compressions, give 2
ued, or they are presented with a legally
breaths until the chest rises visibly.
valid do not resuscitate (DNR) order.
11. Continue the cycle of 30 compressions
followed by 2 ventilations. To establish
the correct rate, count, “One, two, three,
four, five.”
12. If a second rescuer arrives to assist, the and clean inside the mouth thoroughly.
second rescuer should activate EMS if Saturate a clean gauze pad with the solu-
this has not been done. Then both res- tion and lay it on the mouth area for at
cuers can perform CPR on the child. least 30 seconds. Use another gauze pad
to wipe the area dry. Follow manufactur-
a. The first rescuer should finish a cycle
er’s instructions for specific cleaning.
of 30 compressions followed by 2 res-
pirations. NOTE: The 10-percent bleach solution
is more effective than alcohol. Some
b. The second rescuer should locate the
manikins have disposable mouthpieces
proper position on the sternum for
that are discarded after use. If the
compressions. As soon as the first
mouthpiece is discarded, the remainder
rescuer delivers the 2 respirations,
of the face should still be disinfected.
the second rescuer should adminis-
ter 15 compressions. 16. Replace all equipment used. Wash
hands.
c. After 15 compressions, the person
giving compressions pauses very
briefly so the other rescuer can give 2
ventilations.
NOTE: The ratio of compressions to Practice
ventilations is 15:2 for a two-person res- Go to the workbook and use the
cue on a child. evaluation sheet for 16:2D,
Performing CPR on Children, to
d. The rescuers should switch positions
after every six to eight cycles (approx-
imately 2 minutes) of CPR.
13. If an AED is available, one rescuer should instructor for further action.
set up the AED while the other rescuer is
giving cycles of CPR. When the AED is
ready to analyze the heart rhythm, the Final Checkpoint Using the criteria
rescuer operating the AED must make listed on the evaluation sheet, your
sure the other rescuer is clear of the vic- instructor will grade your performance.
First Aid 469
PROCEDURE 16:2E
Performing CPR—
Obstructed Airway
on Conscious Adult
or Child
FIGURE 16-16A Make a fist of one hand.
CPR manikin or choking manikin
cus) but well below the xiphoid
Procedure process at the end of the sternum.
CAUTION: Only a manikin should be d. Grasp the fist with your other hand
used to practice this procedure. Do not (figure 16-16B).
practice on another person. Hand place- e. Use quick, upward thrusts to press
ment can be tried on another person, into the victim’s abdomen (figure
but the actual abdominal thrust should 16-16C).
never be performed unless the person is
choking. NOTE: The thrusts should be delivered
hard enough to cause a force of air to
1. Assemble equipment. Position the man- push the obstruction out of the airway.
ikin in an upright position sitting on a
chair. CAUTION: Make sure that your fore-
arms do not press against the victim’s
2. Determine whether the victim has an rib cage while the thrusts are being per-
airway obstruction. Ask, “Are you chok- formed.
ing?” Check to see whether the victim
can cough or speak. f. If you cannot reach around the vic-
tim to give abdominal thrusts (the
CAUTION: If the victim is coughing victim is very obese), or if a victim is
forcefuly, the airway is not completely in the later stages of pregnancy, give
obstructed. Encourage the victim to chest thrusts. Stand behind the vic-
remain calm and cough hard. Coughing tim. Wrap your arms under the vic-
is usually very effective for removing an tim’s axilla (armpits) and around to
obstruction. the center of the chest. Make a fist
3. If the victim cannot cough, talk, make
noise, or breathe, call for help.
4. Perform abdominal thrusts to try to
remove the obstruction. Follow these
steps:
a. Stand behind the victim.
b. Wrap both arms around the victim’s
waist.
c. Make a fist of one hand (figure
16-16A). Place the thumb side of the
FIGURE 16-16B Place the thumb side of the
fist in the middle of the victim’s abdo-
fist above the umbilicus but well below the
men, slightly above the navel (umbili-
xiphoid process at the end of the sternum.
Grasp the fist with your other hand.
470 CHAPTER 16
PROCEDURE 16:2E
FIGURE 16-17 If an object is visible in the

mouth, use a C-shaped, or hooking, motion to
remove the object.
a. Open the airway.

b. Check breathing for at least 5 but not
c. Look in the mouth and remove the
FIGURE 16-16C Use quick, upward thrusts object if it is visible.
to press into the victim’s abdomen. d. Try giving two breaths.
e. Check the carotid pulse for at least 5
with one hand and place the thumb but not more than 10 seconds.
side of the fist against the center of f. If there is a pulse, continue to try to
the sternum but well above the give breaths and check the pulse
xiphoid process. Grab your fist with every 2 minutes.
your other hand and thrust inward.
g. If there is no pulse, give CPR cycles of
g. Repeat the thrusts until the object is 30 compressions followed by 2 respi-
expelled or until the victim becomes rations.
unconscious.
h. Check the mouth for the object every
5. If the victim loses consciousness, begin time you are ready to give breaths.
CPR. Activate EMS if this has not already
6. Do not stop CPR unless the victim recov-
been done. Then start the cycle of CPR
ers, help arrives to take over, a physician
by opening the airway and checking
or other legally qualified person orders
breathing. The only difference in CPR
you to discontinue the attempt, you are
for a choking victim is that every time
so physically exhausted you cannot
you open the airway you should look in
continue, or the scene suddenly be-
the mouth before giving breaths. If you
comes unsafe.
see an object, use a C-shaped or hook-
ing motion to remove the object (figure 7. Make every effort to obtain medical help
16-17). Perform CPR. for the victim as soon as possible.
First Aid 471
PROCEDURE 16:2E
8. After the practice session, replace all
equipment used. Wash hands.
Practice
evaluation sheet for 16:2E,
Performing CPR—Obstructed
Airway on Conscious Adult or
Child, to practice this procedure.
When you believe you have
mastered this skill, sign the sheet
Final Checkpoint Using the criteria and give it to your instructor for
listed on the evaluation sheet, your further action.
PROCEDURE 16:2F
4. If the infant cannot cry, make any
Performing CPR— sounds, is making a high-pitched noise
Obstructed Airway while inhaling or no noise at all, is turn-
ing cyanotic, and does not appear to be
on Conscious Infant breathing, the airway is completely
obstructed. Activate EMS immediately.
Equipment and Supplies 5. Quickly bare the infant’s chest to expose
CPR infant manikin, alcohol or disinfecting the sternum (breastbone).
solution, gauze sponges 6. Give five back blows. Hold the infant
face down, with your arm supporting
Procedure the infant’s body and your hand sup-
porting the infant’s head and jaw. Posi-
CAUTION: Only an infant manikin tion the head lower than the chest
should be used to practice this proce- (figure 16-18A). Use the heel of your
dure. Do not practice on a real infant. other hand to give five firm back blows
1. Assemble equipment. Kneel or sit with between the infant’s shoulder blades.
the infant in your lap. CAUTION: When performing back
NOTE: An infant is any baby to 1 year of blows on an infant, do not use excessive
age. Health care providers should use force.
the adult choking sequence for any child 7. Support the infant’s head and neck to
older than 1 year. turn the infant face up. Hold the infant
2. Shake the infant gently. Ask, “Are you with your forearm resting on your thigh.
OK?” Keep the infant’s head lower than the
chest.
3. If the infant is conscious and coughing
forcefully, allow the infant to cough. The 8. Give five chest thrusts. Position two to
airway is not completely obstructed and three fingers on the sternum just below
the coughing may expel the object.
472 CHAPTER 16
PROCEDURE 16:2F
10. If the infant becomes unresponsive,
place the infant on a firm surface. Open
the airway and look for an object. If an
object is visible, use a C-shaped or hook-
ing motion to remove it. Then perform
CPR following the normal procedure for
an infant, except look in the mouth
every time you are ready to give
breaths.
a. Attempt to give two breaths.
b. Check the brachial pulse for at least 5
but not more than 10 seconds.
c. If there is a pulse, continue to try to
give breaths and check the pulse
every 2 minutes.
FIGURE 16-18A To give an infant five back
blows, position the infant face down, with the d. If there is no pulse, give CPR cycles of
head lower than the chest. 30 compressions followed by 2 respi-
rations.
an imaginary line drawn between the e. Check the mouth for the object every
nipples. Press straight down five times time you are ready to give breaths.
(figure 16-18B), to compress the ster-
num 1⁄3 to 1⁄2 the depth of the chest. 11. Do not stop CPR unless the infant recov-
ers, help arrives to take over, a physician
9. Continue the cycle of five back blows or other legally qualified person orders
followed by five chest thrusts until EMS you to discontinue the attempt, you are
arrives or the infant becomes unrespon- so physically exhausted you cannot
sive. continue, or the scene suddenly
becomes unsafe.
12. Make every effort to obtain medical help
for the infant as soon as possible.
pad to wipe the area dry. Follow manu-
facturer’s recommendations for specific
cleaning or care.
FIGURE 16-18B Give the infant five chest are discarded after use. If the mouth-
thrusts, keeping the head lower than the chest.
First Aid 473
PROCEDURE 16:2F
piece is discarded, the remainder of the
face should still be disinfected.
14. Replace all equipment used. Wash
hands.
Practice
Performing CPR—Obstructed
Airway on Conscious Infant, to
Final Checkpoint Using the criteria sign the sheet and give it to your
listed on the evaluation sheet, your instructor for further action.
♦ Abrasion: With this type of wound the skin is

16:3 INFORMATION scraped off. Bleeding is usually limited, but
Providing First Aid for Bleeding infection must be prevented because dirt and
contaminants often enter the wound.
and Wounds
♦ Incision: This is a cut or injury caused by a
INTRODUCTION sharp object such as a knife, scissors, or razor
blade. The edges of the wound are smooth
In any health career, as well as in your personal and regular. If the cut is deep, bleeding can be
life, you may need to provide first aid to control heavy and can lead to excessive blood loss. In
bleeding or care for wounds. A wound involves addition, damage to muscles, nerves, and
injury to the soft tissues. Wounds are usually clas- other tissues can occur (figure 16-19).
sified as open or closed. With an open wound,
there is a break in the skin or mucous membrane.
With a closed wound, there is no break in the skin
or mucous membrane but injury occurs to the
underlying tissues. An example of a closed wound
is a bruise or hematoma. Wounds can result in
bleeding, infection, and/or tetanus (lockjaw, a
serious infection caused by bacteria). First aid
care must be directed toward controlling bleed-
ing before the bleeding leads to death, and toward
preventing or obtaining treatment for infection.
TYPES OF OPEN
WOUNDS
FIGURE 16-19 An incision, caused by a sharp
Open wounds are classified into types according object such as a knife or razor blade, can cause
to the injuries that occur. Some main types are heavy bleeding and/or damage to muscles, nerves,
abrasions, incisions, lacerations, punctures, avul- and other tissues. (Courtesy of Ron Stram, MD,
sions, and amputations. Albany Medical Center, Albany, NY)
474 CHAPTER 16
♦ Laceration: This type of wound involves stant and can lead to a large blood loss, but it is
tearing of the tissues by way of excessive force. easier to control. Capillary blood “oozes” from
The wound often has jagged, irregular edges. the wound slowly, is less red than arterial blood,
Bleeding may be heavy. If the wound is deep, and clots easily. The four main methods for con-
contamination may lead to infection. trolling bleeding are listed in the order in which
they should be used: direct pressure, elevation,
♦ Puncture: This type of wound is caused by a pressure bandage, and pressure points.
sharp object such as a pin, nail, or pointed
instrument. Gunshot wounds can also cause CAUTION: If possible, use some type of pro-
puncture wounds that are extremely danger- tective barrier, such as gloves or plastic
ous because the damage is hidden under the wrap, while controlling bleeding. If this is
skin and not visible. With all puncture wounds, not possible in an emergency, use thick lay-
external bleeding is usually limited, but inter- ers of dressings and try to avoid contact of
nal bleeding can occur. In addition, the chance blood with your skin. Wash your hands thor-
for infection is increased and tetanus may oughly and as soon as possible after giving
develop if tetanus bacteria enter the wound. first aid to a bleeding victim.
♦ Avulsion: This type of wound occurs when ♦ Direct pressure: Using your gloved hand over a
tissue is torn or separated from the victim’s thick dressing or sterile gauze, apply pressure
body. It can result in a piece of torn tissue directly to the wound (figure 16-20A). If no
hanging from the ear, nose, hand, or other dressing is available, use a clean cloth or linen-
body part. Bleeding is heavy and usually exten- type towel. In an emergency when no materi-
sive. It is important to preserve the body part als are available, it may even be necessary to
while caring for this type of wound, because a use a bare hand. Continue to apply pressure
surgeon may be able to reattach it. for 5–10 minutes or until the bleeding stops. If
♦ Amputation: This type of injury occurs when blood soaks through the dressing, apply a sec-
a body part is cut off and separated from the ond dressing over the first and continue to
body. Loss of a finger, toe, hand, or other body apply direct pressure. Do not disturb blood
part can occur. Bleeding can be heavy and clots once they have formed. Direct pressure
extensive. Care must be taken to preserve the will usually stop most bleeding.
amputated part because a surgeon may be
able to reattach it. The part should be wrapped
in a cool, moist dressing (use sterile water or
normal saline, if possible) and placed in a
plastic bag. The plastic bag should be kept
cool or placed in ice water and transported
with the victim. The body part should never
be placed directly on ice because ice can freeze
the tissue.
CONTROLLING
BLEEDING
Controlling bleeding is the first priority in caring
for wounds, because it is possible for a victim to
bleed to death in a short period of time. Bleeding
can come from arteries, veins, and capillaries.
Arterial blood usually spurts from a wound,
results in heavy blood loss, and is bright red. Arte-
rial bleeding is life-threatening and must be con- FIGURE 16-20A If possible, use some type of
trolled quickly. Venous blood is slower, steadier, protective barrier, such as gloves or plastic wrap,
and dark red or maroon. Venous bleeding is con- while applying direct pressure to control bleeding.
First Aid 475
♦ Elevation: Raise the injured part above the The main pressure point for the arm is the
level of the victim’s heart to allow gravity to aid brachial artery. It is located on the inside of the
in stopping the blood flow from the wound. arm, approximately halfway between the armpit
Continue applying direct pressure while ele- and the elbow (figure 16-20C). The main pressure
vating the injured part (figure 16-20B). point for the leg is the femoral artery. The pulsa-
tion can be felt at the groin (the front middle
CAUTION: If fractures (broken bones) are point of the upper leg, in the crease where the
present or suspected, the part should not be thigh joins the body) (figure 16-20D). When
elevated. bleeding stops, slowly release pressure on the
♦ Pressure bandage: Apply a pressure bandage pressure point. Continue using direct pressure
to hold the dressings in place. Maintain direct and elevation. If bleeding starts again, be ready to
pressure and elevation while applying the reapply pressure to the correct pressure point.
pressure bandage. The procedure for applying
a pressure bandage is described in step 4 of
Procedure 16:3.
♦ Pressure points: If direct pressure, elevation,
and the pressure bandage do not stop severe
bleeding, it may be necessary to apply pres-
sure to pressure points. By applying pressure
to a main artery and pressing it against an
underlying bone, the main blood supply to the
injured area can be cut off. However, because
this technique also stops circulation to other
parts of the limb, it should not be used any
longer than is absolutely necessary. Direct
pressure and elevation should also be contin-
ued while pressure is being applied to the
pressure point.
FIGURE 16-20C The main pressure point for the

arm is the brachial artery. Pressure is applied to the
artery only until the bleeding stops.
FIGURE 16-20D The main pressure point in the

FIGURE 16-20B Continue to apply direct pres- leg is the femoral artery. Pressure is applied while
sure while elevating the injured part above the level maintaining direct pressure to and elevation of the
of the heart. injured part.
476 CHAPTER 16
After severe bleeding has been controlled, Examples of such objects include splinters, small
obtain medical help for the victim. Do not disturb pieces of glass, small stones, and other similar
any blood clots or remove the dressings that were objects. If the object is at the surface of the skin,
used to control the bleeding, because this may remove it gently with sterile tweezers or tweezers
result in additional bleeding. Make no attempt to wiped clean with alcohol or a disinfectant. Any
clean the wound, because this too is likely to objects embedded in the tissues should be left in
result in additional bleeding. the skin and removed by a physician.
MINOR WOUNDS CLOSED WOUNDS

Closed wounds (those not involving breaks in the
In treating minor wounds that do not involve skin) can occur anywhere in the body as a result
severe bleeding, prevention of infection is the of injury. If the wound is a bruise, cold applica-
first priority. Wash your hands thoroughly before tions can be applied to reduce swelling. Other
treating the wound. Put on gloves to avoid con- closed wounds can be extremely serious and
tamination from blood or fluid draining from the cause internal bleeding that may lead to death.
wound. Use soap and water and sterile gauze, if Signs and symptoms may include pain, tender-
possible, to wash the wound. Wipe in an outward ness, swelling, deformity, cold and clammy skin,
direction, away from the wound. Discard the rapid and weak pulse, a drop in blood pressure,
wipe after each use. Rinse the wound thoroughly uncontrolled restlessness, excessive thirst, vom-
with cool water. Use sterile gauze to gently blot ited blood, or blood in the urine or feces. Get
the wound dry. Apply a sterile dressing or ban- medical help for the victim as soon as possible.
dage. Watch for any signs of infection. Be sure to Check breathing, treat for shock, avoid unneces-
tell the victim to obtain medical help if any signs sary movement, and avoid giving any fluids or
of infection appear. food to the victim.
Infection can develop in any wound. It is
important to recognize the signs of infection and
to seek medical help if they appear. Some signs
and symptoms are swelling, heat, redness, pain,
SUMMARY
fever, pus, and red streaks leading from the While caring for any victim with severe bleeding
wound. Prompt medical care is needed if any of or wounds, always be alert for the signs of shock.
these symptoms occur. Be prepared to treat shock while providing care to
Tetanus bacteria can enter an open wound control bleeding and prevent infection in the
and lead to serious illness and death. Tetanus wound.
infection is most common in puncture wounds At all times, remain calm while providing
and wounds that involve damage to tissue under- first aid. Reassure the victim. Obtain appro-
neath the skin. When this type of wound occurs, priate assistance or medical care as soon as pos-
it is important to obtain information from the sible in every case requiring additional care.
patient regarding his or her last tetanus shot and
to get medical advice regarding protection in the STUDENT: Go to the workbook and complete
form of a tetanus shot or booster. the assignment sheet for 16:3, Providing First Aid
With some wounds, objects can remain in the for Bleeding and Wounds. Then return and con-
tissues or become embedded in the wound. tinue with the procedure.
First Aid 477
PROCEDURE 16:3
CAUTION: Do not disturb blood clots
Providing First Aid for once they have formed. This will cause
Bleeding and Wounds the bleeding to start again.
3. Elevate the injured part above the level
Equipment and Supplies of the victim’s heart unless a fracture or
broken bone is suspected.
Sterile dressings and bandages, disposable
gloves NOTE: This allows gravity to help stop
the blood flow to the area.
Procedure NOTE: Direct pressure and elevation are
Severe Wounds used together. Do not stop direct pres-
sure while elevating the part.
1. Follow the steps of priority care, if indi- 4. To hold the dressings in place, apply a
cated. pressure bandage. Maintain direct pres-
a. Check the scene. Move the victim sure and elevation while applying the
only if absolutely necessary. pressure bandage. To apply a pressure
bandage, proceed as follows:
b. Check the victim for consciousness
and breathing. a. Apply additional dressings over the
dressings already on the wound.
c. Call emergency medical services
(EMS). b. Use a roller bandage to hold the
dressings in place by wrapping the
d. Provide care to the victim.
roller bandage around the dressings.
2. To control severe bleeding, proceed as Use overlapping turns to cover the
follows: dressings and to hold them securely
a. If possible, put on gloves or wrap in place.
your hands in plastic wrap to provide c. Tie off the ends of the bandage by
a protective barrier while controlling placing the tie directly over the dress-
bleeding. If this is not possible in an ings (figure 16-21).
emergency, use thick layers of dress-
ings and try to avoid contact of blood
with your skin.
b. Using your hand over a thick dress-
ing or sterile gauze, apply pressure
directly to the wound.
c. Continue to apply pressure to the
wound for approximately 5–10 min-
utes. Do not release the pressure to
check whether the bleeding has
stopped.
d. If blood soaks through the first dress-
ing, apply a second dressing on top
of the first dressing, and continue to
apply direct pressure.
FIGURE 16-21 Tie the ends of the bandage
NOTE: If sterile gauze is not available, directly over the dressings to secure a pressure
use clean material or a bare hand. bandage.
478 CHAPTER 16
PROCEDURE 16:3
d. Make sure the pressure bandage is soon as possible. Severe bleeding is a
secure. Check a pulse site below the life-threatening emergency.
pressure bandage to make sure the
8. While caring for any victim experienc-
bandage is not too tight. A pulse
ing severe bleeding, be alert for the signs
should be present and there should
and symptoms of shock. Treat the vic-
be no discoloration of the skin to
tim for shock if any signs or symptoms
indicate impaired circulation. If any
are noted.
signs of impaired circulation are
present, loosen and replace the pres- 9. During treatment, constantly reassure
sure bandage. the victim. Encourage the victim to
remain calm by remaining calm your-
5. If the bleeding continues, it may be nec-
self.
essary to apply pressure to the appro-
priate pressure point. Continue using 10. After controlling the bleeding, wash
direct pressure and elevation, and apply your hands as thoroughly and quickly as
pressure to the pressure point as fol- possible to avoid possible contamina-
lows: tion from the blood. Wear gloves and
use a disinfectant solution to wipe up
a. If the wound is on the arm or hand,
any blood spills. Always wash your
apply pressure to the brachial artery.
hands thoroughly after removing
Place the flat surface of your fingers
gloves.
(not your fingertips) against the
inside of the victim’s upper arm,
approximately halfway between the Procedure
elbow and axilla area. Position your Minor Wounds
thumb on the outside of the arm.
Press your fingers toward your thumb 1. Wash hands thoroughly with soap and
to compress the brachial artery and water. Put on gloves.
decrease the supply of blood to the 2. Use sterile gauze, soap, and water to
arm (refer to figure 16-20C). wash the wound. Start at the center and
b. If the wound is on the leg, place the wash in an outward direction. Discard
flat surfaces of your fingers or the the gauze after each pass.
heel of one hand directly over the 3. Rinse the wound thoroughly with cool
femoral artery where it passes over water to remove all of the soap.
the pelvic bone. The position is on
the front, middle part of the upper 4. Use sterile gauze to dry the wound. Blot
thigh (groin) where the leg joins the it gently.
body. Straighten your arm and apply 5. Apply a sterile dressing to the wound.
pressure to compress the femoral
artery and to decrease the blood sup- 6. Caution the victim to look for signs of
ply to the leg (refer to figure 16-20D). infection. Tell the victim to obtain medi-
cal care if any signs of infection appear.
6. When the bleeding stops, slowly release
the pressure on the pressure point while 7. If tetanus infection is possible (for
continuing to use direct pressure and example, in cases involving puncture
elevation. If the bleeding starts again, be wounds), tell the victim to contact a
ready to reapply pressure to the pres- doctor regarding a tetanus shot.
sure point. CAUTION: Do not use any antiseptic
7. Obtain medical help for the victim as solutions to clean the wound and do not
First Aid 479
PROCEDURE 16:3
apply any substances to the wound
unless specifically instructed to do so by
a physician or your immediate supervi-
sor. Practice
8. Obtain medical help as soon as possible evaluation sheet for 16:3, Providing
for any victim requiring additional care. First Aid for Bleeding and Wounds,
Any victim who has particles embedded to practice these procedures. When
in a wound, risk for tetanus, severe
you believe you have mastered these
bleeding, or other complications must
skills, sign the sheet and give it to
be referred for medical care.
your instructor for further action.
9. When care is complete, remove gloves
and wash hands thoroughly.

circulation and decrease the supply of oxygen to

16:4 INFORMATION body cells, tissues, and organs.
Providing First Aid for Shock
INTRODUCTION SIGNS AND SYMPTOMS
When shock occurs, the body attempts to increase
Shock is a state that can exist with any injury or blood flow to the brain, heart, and vital organs by
illness requiring first aid. It is important that you reducing blood flow to other body parts. This can
are able to recognize it and provide treatment. lead to the following signs and symptoms that
Shock, also called hypoperfusion, can be indicate shock:
defined as “a clinical set of signs and symptoms
associated with an inadequate supply of blood to ♦ Skin is pale or cyanotic (bluish gray) in color.
body organs, especially the brain and heart.” If it Check the nail beds and the mucous mem-
is not treated, shock can lead to death, even when brane around the mouth.
a victim’s injuries or illness might not themselves ♦ Skin is cool to the touch.
be fatal. After just 4–6 minutes of hypoperfusion,
♦ Diaphoresis, or excessive perspiration, may
brains cells are damaged irreversibly.
result in a wet, clammy feeling when the skin
is touched.
CAUSES OF SHOCK ♦ Pulse is rapid, weak, and difficult to feel. Check
the pulse at one of the carotid arteries in the
Many different things can cause the victim to neck.
experience shock: hemorrhage (excessive loss ♦ Respirations are rapid, shallow, and may be
of blood); excessive pain; infection; heart attack; irregular.
stroke; poisoning by chemicals, drugs, or gases;
lack of oxygen; psychological trauma; and dehy- ♦ Blood pressure is very low or below normal,
dration (loss of body fluids) from burns, vomit- and may not be obtainable.
ing, or diarrhea. The eight main types of shock ♦ Victim experiences general weakness. As
are shown in Table 16-1. All types of shock impair shock progresses, the victim becomes listless
480 CHAPTER 16
TABLE 16-1 Types of Shock

TYPE OF SHOCK CAUSE DESCRIPTION
Anaphylactic Hypersensitive or allergic reaction to a Body releases histamine causing vasodilation (blood
substance such as food, medications, vessels get larger)
insect stings or bites, or snake bites Blood pressure drops and less blood goes to body cells
Urticaria (hives) and respiratory distress may occur
Cardiogenic Damage to heart muscle from heart Heart cannot effectively pump blood to body cells
attack or cardiac arrest
Hemorrhagic Severe bleeding or loss of blood plasma Decrease in blood volume causes blood pressure to drop
Decreased blood flow to body cells
Metabolic Loss of body fluid from severe Decreased amount of fluid causes dehydration and
vomiting, diarrhea, or a heat illness disruption in normal acid–base balance of body
Disruption in acid–base balance as Blood pressure drops and less blood circulates to body
occurs in diabetes cells
Neurogenic Injury and trauma to brain and/or spinal Nervous system loses ability to control the size of blood
cord vessels
Blood vessels dilate and blood pressure drops
Decreased blood flow to body cells
Psychogenic Emotional distress such as anger, fear, Emotional response causes sudden dilation of blood
or grief vessels
Blood pools in areas away from the brain
Some individuals faint
Respiratory Trauma to respiratory tract Interferes with exchange of oxygen and carbon dioxide
Respiratory distress or arrest (chronic between lungs and bloodstream
disease, choking) Insufficient oxygen supply for body cells
Septic Acute infection (toxic shock syndrome) Poisons or toxins in blood cause vasodilation
Blood pressure drops
Less oxygen to body cells
and confused. Eventually, the victim loses toward (1) eliminating the cause of shock; (2)
consciousness. improving circulation, especially to the brain and
♦ Victim experiences anxiety and extreme rest- heart; (3) providing an adequate oxygen supply;
lessness. and (4) maintaining body temperature. Some of
the basic principles for treatment are as follows:
♦ Victim may experience excessive thirst, nau-
sea, and/or vomiting. ♦ Reduce the effects of or eliminate the cause of
shock: control bleeding, provide oxygen if
♦ Victim may complain of blurred vision. As available, ease pain through position change,
shock progresses, the victim’s eyes may appear and/or provide emotional support.
sunken and have a vacant or confused expres-
sion. The pupils may dilate or become large. ♦ The position for treating shock must be based
on the victim’s injuries.
CAUTION: If neck or spine injuries are sus-
TREATMENT pected, the victim should not be moved
FOR SHOCK unless it is necessary to remove him or her
from danger.
It is essential to get medical help for the victim as The best position for treating shock is usually
soon as possible because shock is a life-threaten- to keep the victim lying flat on the back, because
ing condition. Treatment for shock is directed this improves circulation. Raising the feet and legs
First Aid 481
approximately 12 inches can also provide addi- tant to avoid overheating the victim. If the
tional blood for the heart and brain. However, if skin is very warm to the touch and perspira-
the victim is vomiting or has bleeding and injuries tion is noted, remove some of the blankets or
of the jaw or mouth, the victim should be posi- coverings.
tioned on the side to prevent him or her from ♦ Avoid giving the victim anything to eat or
choking on blood and/or vomitus. If a victim is drink. If the victim complains of excessive
experiencing breathing problems, it may be nec- thirst, a wet cloth can be used to provide some
essary to raise the victim’s head and shoulders to comfort by moistening the lips and mouth.
make breathing easier. If the victim has a head
(not neck) injury and has difficulty breathing, the Remember that it is important to look for
victim should be positioned lying flat or with the signs of shock while providing first aid for any
head raised slightly. It is important to position the injury or illness. Provide care that will reduce the
victim based on the injury or illness involved. effect of shock. Obtain medical help for the vic-
tim as soon as possible.
♦ Cover the patient with blankets or additional
clothing to prevent chilling or exposure to the STUDENT: Go to the workbook and complete
cold. Blankets may also be placed between the the assignment sheet for 16:4, Providing First Aid
ground and the victim. However, it is impor- for Shock. Then return and continue with the pro-
cedure.
PROCEDURE 16:4
3. Observe the victim for any signs of
Providing First Aid shock. Look for a pale or cyanotic (blu-
for Shock ish) color to the skin. Touch the skin and
note if it is cool, moist, or clammy to the
Equipment and Supplies touch. Note diaphoresis, or excessive
perspiration. Check the pulse to see if it
Blankets, watch with second hand (optional), is rapid, weak, or irregular. If you are
disposable gloves unable to feel a radial pulse, check the
carotid pulse. Check the respirations to
Procedure see if they are rapid, weak, irregular,
shallow, or labored. If equipment is
1. Follow the steps of priority care, if indi- available, check blood pressure to see if
cated. it is low. Observe the victim for signs of
a. Check the scene. Move the victim weakness, apathy, confusion, or con-
only if absolutely necessary. sciousness. Note if the victim is nause-
ated or vomiting, complaining of
b. Check the victim for consciousness excessive thirst, restless or anxious, or
and breathing. complaining of blurred vision. Examine
c. Call emergency medical services the eyes for a sunken, vacant, or con-
(EMS). fused appearance, and dilated pupils.
d. Provide care to the victim. 4. Try to reduce the effects or eliminate the
cause of shock:
e. Control severe bleeding.
a. Control bleeding by applying pres-
CAUTION: If possible, wear gloves or sure at the site.
use a protective barrier while control-
ling bleeding. b. Provide oxygen, if possible.
2. Obtain medical help for the victim as c. Attempt to ease pain through posi-
soon as possible. Call or send someone tion changes and comfort measures.
to obtain help. d. Give emotional support.
482 CHAPTER 16
PROCEDURE 16:4
5. Position the victim based on the injuries CAUTION: Do not raise the legs if the
or illness present. victim has head, neck, or back injuries,
or if there are possible fractures of the
a. If an injury of the neck or spine is
hips or legs.
present or suspected, do not move
the victim. f. If in doubt on how to position a vic-
tim according to the injuries involved,
b. If the victim has bleeding and inju-
keep the victim lying down flat or in
ries to the jaw or mouth, or is vomit-
the position in which you found him
ing, position the victim’s body on
or her. Avoid any unnecessary move-
either side. This allows fluids, vomi-
ment.
tus, and/or blood to drain and pre-
vents the airway from becoming 6. Place enough blankets or coverings on
blocked by these fluids. the victim to prevent chilling. Some-
times, a blanket can be placed between
c. If the victim is having difficulty
the victim and the ground. Avoid over-
breathing, position the victim on the
heating the victim.
back, but raise the head and shoul-
ders slightly to aid breathing. 7. Do not give the victim anything to eat or
drink. If the victim complains of exces-
d. If the victim has a head injury, posi-
sive thirst, use a moist cloth to wet the
tion the victim lying flat or with the
lips, tongue, and inside of the mouth.
head raised slightly.
8. Constantly reassure the victim. Encour-
NOTE: Never allow the head to be posi-
age the victim to remain calm by remain-
tioned lower than the rest of the body.
ing calm yourself.
e. If none of these conditions exist,
9. Observe and provide care to the victim
position the victim lying flat on the
until medical help is obtained.
back. To improve circulation, raise
the feet and legs approximately 12 10. Replace all equipment used. Wash
inches (figure 16-22). If raising the hands.
legs causes pain or leads to difficult
breathing, however, lower the legs to
the flat position.
Practice
evaluation sheet for 16:4, Providing
First Aid for Shock, to practice this
for further action.
FIGURE 16-22 Position a shock victim flat on

the back and elevate the feet and legs approxi-
mately 12 inches. Do not use this position if the Final Checkpoint Using the criteria
victim has a neck, spinal, head, or jaw injury, or listed on the evaluation sheet, your
if the victim is having difficulty breathing. instructor will grade your performance.
First Aid 483
may recommend giving syrup of ipecac fol-

16:5 INFORMATION lowed by a glass of water. Recent studies have
shown that syrup of ipecac can cause dehydra-
Providing First Aid for Poisoning tion and confusion, so it should only be given if
INTRODUCTION recommended by the PCC or a physician. Fol-
low dosage recommended on bottle. Syrup of
Poisoning can occur anywhere, anytime—not ipecac is available in most drug stores and can
only in health care settings, but also in your per- be kept in a first aid kit for poisoning victims.
sonal life. Poisoning can happen to any individ- CAUTION: Vomiting must not be induced in
ual, regardless of age. It can be caused by ingesting unconscious victims, victims who swal-
(swallowing) various substances, inhaling poi- lowed an acid or alkali, victims who swal-
sonous gases, injecting substances, or contacting lowed petroleum products, victims who are
the skin with poison. Any substance that causes a convulsing, or victims who have burns on
harmful reaction when applied or ingested can the lips and mouth.
be called a poison. Immediate action is necessary
♦ Activated charcoal may be recommended by
for any poisoning victim. Treatment varies
the PCC to bind to the poison so it is not
depending on the type of poison, the injury
absorbed into the body. Activated charcoal
involved, and the method of contact.
should only be given to victims who are con-
If the poisoning victim is unconscious, check
scious and able to swallow. It is available in
for breathing. Provide artificial respiration if the
most drug stores. The directions on the bottle
victim is not breathing. Obtain medical help as
should be followed to determine the correct
soon as possible. If the unconscious victim is
dosage.
breathing, position the victim on his or her side
so fluids can drain from the mouth. Obtain medi-
cal help quickly.
INHALATION POISONING
If poisoning is caused by inhalation of dangerous
INGESTION POISONING gases, the victim must be removed immediately
from the area before being treated. A commonly
If a poison has been swallowed, immediate inhaled poison is carbon monoxide. It is odorless,
care must be provided before the poison colorless, and very difficult to detect. Basic steps
can be absorbed into the body. Basic steps of first of first aid include:
aid include:
♦ Before entering the danger area, take a deep
♦ Call a poison control center (PCC) or a physi- breath of fresh air and do not breathe the gas
cian immediately. If you cannot contact a PCC, while you are removing the victim from the
call emergency medical services (EMS). Most area.
areas have poison control centers that provide
information on specific antidotes and treat-
♦ After rescuing the victim, immediately check
for breathing.
ment.
♦ Save the label or container of the substance ♦ Provide artificial respiration if needed.
taken so this information can be given to the ♦ Obtain medical help immediately; death may
PCC or physician. occur very quickly with this type of poisoning.
♦ Calculate or estimate how much was taken
and the time at which the poisoning
occurred. CONTACT POISONING
♦ If the victim vomits, save a sample of the vom- If poisoning is caused by chemicals or poisons
ited material. coming in contact with the victim’s skin, care for
♦ If the PCC tells you to induce vomiting, get the the victim includes:
victim to vomit. To induce vomiting, tickle the ♦ Use large amounts of water to wash the skin
back of the victim’s throat or give the victim for at least 15–20 minutes to dilute the sub-
warm saltwater to drink. In some cases, the PCC stance and remove it from the skin.
484 CHAPTER 16
♦ Remove any clothing and jewelry that contain ♦ Wash the area thoroughly with soap and
the substance. water.
♦ Call a PCC or physician for additional infor- ♦ Apply an antiseptic.
mation. ♦ Watch for signs of infection.
♦ Obtain medical help as soon as possible for ♦ Obtain medical help if needed.
burns or injuries that may result from contact
with the poison. Ticks can cause Rocky Mountain spotted
fever or Lyme disease, dangerous diseases if
Contact with a poisonous plant such as poi- untreated.
son ivy, oak, or sumac can cause a serious skin
reaction if not treated immediately. Basic steps of
For a snakebite or spider bite, first aid treat-
first aid include:
ment includes:
♦ Wash the area thoroughly with soap and ♦ Wash the wound.
water
♦ Immobilize the injured area, positioning it
♦ If a rash or weeping sores develop after 2–3 lower than the heart, if possible.
days, lotions such as Calamine or Caladryl, or
a paste made from baking soda and water may ♦ Do not cut the wound or apply a tourniquet.
help relieve the discomfort. ♦ Monitor the breathing of the victim and give
♦ If the condition is severe and affects large artificial respiration if necessary.
areas of the body or face, obtain medical help. ♦ Obtain medical help for the victim as soon as
possible.
For any type of injection poisoning, watch for
INJECTION POISONING allergic reaction in all victims (figure 16-23). Signs
and symptoms of allergic reaction include red-
Injection poisoning occurs when an insect, spi- ness and swelling at the site, itching, hives, pain,
der, or snake bites or stings an individual. If an swelling of the throat, difficult or labored breath-
arm or leg is affected, position the affected area ing, dizziness, and a change in the level of con-
below the level of the heart. For an insect sting, sciousness. Maintain respirations and obtain
first aid treatment includes: medical help as quickly as possible for the victim
♦ Remove any embedded stinger by scraping who experiences an allergic reaction.
the stinger away from the skin with the edge of
a rigid card, such as a credit card, or a tongue
depressor. Do not use tweezers because twee- SUMMARY
zers can puncture the venom sac attached to
In all poisoning victims, observe for signs of
the stinger, injecting more poison into body
anaphylactic shock. Treat the victim for
tissues.
shock, if necessary. Try to remain calm and confi-
♦ Wash the area well with soap and water. dent while providing first aid for poisoning vic-
♦ Apply a sterile dressing and a cold pack to tims. Reassure the victim as needed. Act quickly
reduce swelling. and in an organized, efficient manner.
If a tick is embedded in the skin, first aid treat-
ment includes:
the assignment sheet for 16:5, Providing First Aid
♦ Use tweezers to slowly pull the tick out of the for Poisoning. Then return and continue with the
skin. procedure.
First Aid 485
Skin hives Edema
Airway
100
90 110
80 120
70 130
60 140
Bronchial constriction Hypotension
100
Bee sting 90 110
80 120
70 130
60 140
Alveoli passages
are very narrow
FIGURE 16-23 Watch for allergic reactions in all poisoning victims.
486 CHAPTER 16
PROCEDURE 16:5
c. Follow the instructions received from
Providing First Aid the PCC. Obtain medical help if
for Poisoning needed.
d. If the victim vomits, save a sample of
Equipment and Supplies the vomited material.
Telephone, disposable gloves 4. If the PCC tells you to get the victim to
vomit, induce vomiting. Give the victim
Procedure warm salt water or tickle the back of the
victim’s throat. Syrup of ipecac is also
1. Follow the steps of priority care, if indi- used to induce vomiting, but it should
cated: not be given to a victim unless the PCC
or a physician tells you to use it.
a. Check the scene. Move the victim
only if absolutely necessary. CAUTION: Do not induce vomiting if
the victim is unconscious or convulsing,
has burns on the lips or mouth, or has
and breathing.
swallowed an acid, alkali, or petroleum
c. Call emergency medical services product.
(EMS).
5. If the PCC tells you to give the victim
d. Provide care to the victim. activated charcoal, follow the directions
e. Control severe bleeding. on the container. Make sure the victim
is conscious and able to swallow before
CAUTION: If possible, wear gloves or giving the charcoal.
ling bleeding. NOTE: Activated charcoal binds to the
poison so it is not absorbed into the
2. Check the victim for signs of poisoning. body.
Signs may include burns on the lips or
mouth, odor, a container of poison, or 6. If the victim is unconscious:
presence of the poisonous substance on a. Check for breathing. If the victim is
the victim or in the victim’s mouth. not breathing, give artificial respira-
Information may also be obtained from tion and/or CPR as needed.
the victim or from an observer. b. If the victim is breathing, position
3. If the victim is conscious, not convuls- the victim on his or her side to allow
ing, and has swallowed a poison: fluids to drain from the mouth.
a. Try to determine the type of poison, c. Call a PCC or physician for specific
how much was taken, and when the treatment. Obtain medical help
poison was taken. Look for the con- immediately.
tainer near the victim. d. If possible, save the poison container
b. Call a poison control center (PCC) or and a sample of any vomited mate-
physician immediately for specific rial. Check with any observers to find
information on how to treat the poi- out what was taken, how much was
soning victim. Provide as much infor- taken, and when the poison was
mation as possible. taken.
7. If chemicals or poisons have splashed
on the victim’s skin, wash the area thor-
oughly with large amounts of water.
First Aid 487
PROCEDURE 16:5
Remove any clothing and jewelry con- antiseptic. Obtain medical help if
taining the substance. If a large area of needed.
the body is affected, a shower, tub, or
d. For a snakebite, wash the wound.
garden hose may be used to rinse the
Immobilize the injured area, posi-
skin. Obtain medical help immediately
tioning it lower than the heart if pos-
for burns or injuries caused by the
sible. Monitor the breathing of the
poison.
victim and give artificial respiration
8. If the victim has come in contact with a if necessary. Obtain medical help for
poisonous plant such as poison ivy, oak, the victim as soon as possible.
or sumac, wash the area of contact thor-
e. Watch for the signs and symptoms of
oughly with soap and water. Remove
allergic reaction in all victims. Signs
any contaminated clothing. If a rash or
and symptoms of allergic reaction
weeping sores develop in the next few
include redness and swelling at the
days after exposure, lotions such as Cal-
site, itching, hives (figure 16-24),
amine or Caladryl, or a paste made from
pain, swelling of the throat, difficult
baking soda and water, may help relieve
or labored breathing, dizziness, and a
the discomfort. If the condition is severe
change in the level of consciousness.
and affects large areas of the body or
Maintain respirations and obtain
face, obtain medical help.
medical help as quickly as possible
9. If the victim has inhaled poisonous gas, for the victim experiencing an aller-
do not endanger your life by trying to gic reaction.
treat the victim in the area of the gas.
11. Observe for signs of anaphylactic shock
Take a deep breath of fresh air before
while treating any poisoning victim.
entering the area and hold your breath
Treat for shock as necessary.
while you remove the victim from the
area. When the victim is in a safe area,
check for breathing. Provide artificial
respiration and/or CPR as needed.
Obtain medical help immediately.
10. If poisoning is caused by injection from
an insect bite or sting or a snakebite,
proceed as follows:
a. If an arm or leg is affected, position
the affected area below the level of
the heart.
b. For an insect bite, remove any
embedded stinger by scraping it off
with an object like a credit card. Wash
the area well with soap and water.
Apply a sterile dressing and a cold
pack to reduce swelling.
c. If a tick is embedded in the skin, use FIGURE 16-24 Hives are a common sign of
tweezers to gently pull the tick out of an allergic reaction. (Courtesy of Robert A.
the skin. Wash the area thoroughly Silverman, MD, Clinical Associate Professor,
with soap and water, and apply an Department of Pediatrics, Georgetown Univer-
sity, Georgetown, MD)
488 CHAPTER 16
PROCEDURE 16:5
12. Remain calm while treating the victim.
Reassure the victim.
13. Always obtain medical help for any poi-
soning victim. Some poisons may have
Practice
delayed reactions. Always keep the tele- evaluation sheet for 16:5, Providing
phone numbers of a PCC and other First Aid for Poisoning, to practice
sources of medical assistance in a con- this procedure. When you believe
venient location so you will be prepared
to provide first aid for poisoning.
14. Wash hands thoroughly after providing instructor for further action.
care.

may take 3–4 weeks to heal. Frequent causes

16:6 INFORMATION include excessive exposure to the sun, a sun-
lamp, or artificial radiation; contact with hot
Providing First Aid for Burns or boiling liquids; and contact with fire.
TYPES OF BURNS ♦ Full-thickness, or third-degree, burn: This is
the most severe type of burn and involves
A burn is an injury that can be caused by fire, injury to all layers of the skin plus the underly-
heat, chemical agents, radiation, and/or electric- ing tissue. The area involved has a white or
ity. Burns are classified as either superficial, par- charred appearance. This type of burn can be
tial thickness, or full thickness (figure 16-25). either extremely painful or, if nerve endings
Characteristics of each type of burn are as fol- are destroyed, relatively painless. Third-degree
lows: burns can be life-threatening because of
fluid loss, infection, and shock. Frequent
♦ Superficial, or first-degree, burn: This is the
causes include exposure to fire or flames, pro-
least severe type of burn. It involves only the
longed contact with hot objects, contact with
top layer of skin, the epidermis, and usually
electricity, and immersion in hot or boiling
heals in 5–6 days without permanent scarring.
liquids.
The skin is usually reddened or discolored.
There may be some mild swelling, and the
victim feels pain. Three common causes are
overexposure to the sun (sunburn), brief con- TREATMENT
tact with hot objects or steam, and exposure First aid treatment for burns is directed toward
of the skin to a weak acid or alkali. removing the source of heat, cooling the affected
♦ Partial-thickness, or second-degree, burn: This skin area, covering the burn, relieving pain,
type of burn involves injury to the top layers of observing and treating for shock, and preventing
skin, including both the epidermis and der- infection. Medical treatment is not usually
mis. A blister or vesicle forms. The skin is red required for superficial and mild partial-thick-
or has a mottled appearance. Swelling usually ness burns. However, medical care should be
occurs, and the surface of the skin frequently obtained if more than 15 percent of the surface of
appears to be wet. This is a painful burn and an adult’s body is burned (10 percent in a child).
First Aid 489
Epidermis
Dermis
Subcutaneous
fat, muscle
Skin red, dry Superficial, first degree
Blistered, skin moist, pink or red Partial thickness,

second degree
Charring, skin black, brown, red Full thickness, third degree

FIGURE 16-25 Types of burns
The rule of nines is used to calculate the percent- Superficial and Mild Partial-
age of body surface burned (figure 16-26). Medi-
cal care should also be obtained if the burns affect
Thickness Burns
the face or respiratory tract; if the victim has dif- The main treatment for superficial and mild
ficulty breathing; if burns cover more than one partial-thickness burns is to cool the area by
body part; if the victim has a partial-thickness flushing it with large amounts of cool water. Do
burn and is under 5 or over 60 years of age; or if not use ice or ice water on burns because doing
the burns resulted from chemicals, explosions, or so causes the body to lose heat. After the pain
electricity. All victims with full-thickness burns subsides, use dry, sterile gauze to blot the area
should receive medical care. dry. Apply a dry, sterile dressing to prevent infec-
490 CHAPTER 16
Provide artificial respiration and treatment for

41/2% 41/2%
shock, as necessary. Watch the victim closely until
medical help arrives.
18%
18%
41/2% 41/2% 41/2% 41/2%

Chemical Burns
For burns caused by chemicals splashing on the
skin, use large amounts of water to flush the
1%
affected areas for 15–30 minutes or until medical
9% 9% 9% 9% help arrives. Gently remove any clothing, socks
and shoes, or jewelry that contains the chemical
to minimize the area injured. Continue flushing
the skin with cool water and watch the victim for
signs of shock until medical help can be
obtained.
If the eyes have been burned by chemicals or
irritating gases, flush the eyes with large amounts
FIGURE 16-26 The rule of nines is used to of water for at least 15–30 minutes or until medi-
calculate the percentage of body surface burned.
cal help arrives. If only one eye is injured, be sure
to tilt the victim’s head in the direction of the
tion. If nonadhesive dressings are available, it is
injury so the injured eye can be properly flushed.
best to use them because they will not stick to the
Start at the inner corner of the eye and allow the
injured area. If possible, elevate the affected part
water to run over the surface of the eye and to the
to reduce swelling caused by inflammation. If
outside. Continue flushing the eye with cool
necessary, obtain medical help.
water and watch the victim for signs of shock
CAUTION: Do not apply cotton, tissues, until medical help can be obtained.
ointment, powders, oils, grease, butter, or
CAUTION: Make sure that the water (or
any other substances to the burned area
remaining chemical) does not enter the
unless you are instructed to do so by a phy-
uninjured eye.
sician or your immediate supervisor. Do not
break or open any blisters that form on
burns because doing so will just cause an
open wound that is prone to infection.
SUMMARY
Loss of body fluids (dehydration) can occur very
quickly with severe burns, so shock is frequently
Severe Partial-Thickness and noted in burn victims. Be alert for any signs of
shock and treat the burn victim for shock imme-
Full-Thickness Burns diately.
Call for medical help immediately if the victim Remain calm while treating the burn victim.
has severe partial-thickness or full-thickness Reassure the victim. Obtain medical help as
burns. Cover the burned areas with thick, sterile quickly as possible for any burn victim requiring
dressings. Elevate the hands or feet if they are medical assistance.
burned. If the feet or legs are burned, do not allow
the victim to walk. If particles of clothing are STUDENT: Go to the workbook and complete
attached to the burned areas, do not attempt to the assignment sheet for 16:6, Providing First Aid
remove these particles. Watch the victim closely for Burns. Then return and continue with the pro-
for signs of respiratory distress and/or shock. cedure.
First Aid 491
PROCEDURE 16:6
Providing First Aid
for Burns
Water, sterile dressings, disposable gloves
Procedure
1. Follow the priorities of care, if indi-
cated:
a. Check the scene. Move the victim FIGURE 16-27A The skin is wet, red, swol-
only if absolutely necessary. len, painful, and blistered when a partial-
b. Check the victim for consciousness thickness burn is present. (Courtesy of the
and breathing. Phoenix Society of Burn Survivors, Inc.)

(EMS) if necessary. applying cold water until the pain
subsides.
b. Use sterile gauze to gently blot the
e. Check for bleeding. Control severe
injured area dry.
bleeding.
c. Apply dry, sterile dressings to the
CAUTION: If possible, wear gloves or
burned area. If possible, use nonad-
hesive (nonstick) dressings, because
ling bleeding.
they will not stick to the burn.
2. Check the burned area carefully to
d. If blisters are present, do not break or
determine the type of burn. A reddened
open them.
or discolored area is usually a superfi-
cial, or first-degree, burn. If the skin is
wet, red, swollen, painful, and blistered,
the burn is usually a partial-thickness,
or second-degree, burn (figure 16-27A).
If the skin is white or charred and there
is destruction of tissue, the burn is a
full-thickness, or third-degree, burn
(figure 16-27B).
NOTE: Victims can have more than one
type of burn at one time. Treat for the
most severe type of burn present.
3. For a superficial or mild partial-thick-
ness burn:
FIGURE 16-27B A full-thickness burn
a. Cool the burn by flushing it with large
destroys or affects all layers of the skin plus fat,
amounts of cool water. If this is not muscle, bone, and nerve tissue. The skin is
possible, apply clean or sterile cloths white or charred in appearance. (Courtesy of
that are cold and wet. Continue the Phoenix Society of Burn Survivors, Inc.)
492 CHAPTER 16
PROCEDURE 16:6
e. If possible, elevate the burned area to 6. If the eye has been burned by chemicals
reduce swelling caused by inflamma- or irritating gases:
tion.
a. If the victim is wearing contact lenses
f. Obtain medical help for burns to the or glasses, ask him or her to remove
face, or if burns cover more than 15 them quickly.
percent of the surface of an adult’s
b. Tilt the victim’s head toward the
body or 10 percent of the surface of a
injured side.
child’s body. If the victim is having
difficulty breathing, or any other dis- c. Hold the eyelid of the injured eye
tress is noted, obtain medical help. open. Pour cool water from the inner
part of the eye (the part closest to the
g. Do not apply any cotton, ointment,
nose) toward the outer part (figure
powders, grease, butter, or similar
16-28).
substances to the burned area.
d. Use cool water to irrigate the eye for
NOTE: These substances may increase
15–30 minutes or until medical help
the possibility of infection.
arrives.
4. For a severe partial-thickness or any
CAUTION: Take care that the water or
full-thickness burn:
chemicals do not enter the uninjured
a. Call for medical help immediately. eye.
b. Use thick, sterile dressings to cover e. Obtain medical help immediately.
the injured areas.
7. Observe for the signs of shock in all burn
c. Do not attempt to remove any parti- victims. Treat for shock as necessary.
cles of clothing that have stuck to the
burned areas.
d. If the hands and arms or legs and feet
are affected, elevate these areas.
e. If the victim has burns on the face or
is experiencing difficulty in breath-
ing, elevate the head.
f. Watch the victim closely for signs of
shock and provide care if necessary.
5. For a burn caused by a chemical splash-
ing on the skin:
a. Using large amounts of water, imme-
diately flush the area for 15–30 min-
utes or until medical help arrives.
b. Remove any articles of clothing,
socks and shoes, or jewelry contami-
nated by the substance.
c. Continue flushing the area with large
amounts of cool water.
FIGURE 16-28 To irrigate an eye, hold the
d. Obtain medical help immediately. eyelid open and irrigate from the inner part of
the eye toward the outer part.
First Aid 493
PROCEDURE 16:6
8. Reassure the victim as you are providing
treatment. Remain calm and encourage
the victim to remain calm.
9. Obtain medical help immediately for
Practice
any burn victim with extensive burns, evaluation sheet for 16:6, Providing
full-thickness burns, burns to the face, First Aid for Burns, to practice this
signs of shock, respiratory distress, eye procedure. When you believe you
burns, and/or chemical burns to the
skin.
10. Wash hands thoroughly after providing for further action.
care.

16:7 INFORMATION
Providing First Aid for Heat
Exposure
Excessive exposure to heat or high external tem-
peratures can lead to a life-threatening emer-
gency (figure 16-29). Overexposure to heat can
cause a chemical imbalance in the body that can
eventually lead to death. Harmful reactions can
occur when water or salt are lost through perspi-
ration or when the body cannot eliminate excess
heat.
Heat cramps are caused by exposure to
heat. They are muscle pains and spasms that
result from the loss of water and salt through per-
spiration. Firm pressure applied to the cramped
muscle will provide relief from the discomfort.
The victim should rest and move to a cooler area.
In addition, small sips of water or an electrolyte
solution, such as sport drinks, can be given to the
victim. FIGURE 16-29 Excessive exposure to heat or
Heat exhaustion occurs when a victim is high external temperatures can lead to a life-
exposed to heat and experiences a loss of fluids threatening emergency. (Courtesy of the Phoenix
through sweating. Signs and symptoms include Society of Burn Survivors, Inc.)
pale and clammy skin, profuse perspiration (dia-
phoresis), fatigue or tiredness, weakness, head- possible. If it is not treated, it can develop into
ache, muscle cramps, nausea and/or vomiting, heat stroke. Treatment methods include moving
and dizziness and/or fainting. Body temperature the victim to a cooler area whenever possible;
is about normal or just slightly elevated. It is loosening or removing excessive clothing; apply-
important to treat heat exhaustion as quickly as ing cool, wet cloths; laying the victim down and
494 CHAPTER 16
elevating the victim’s feet 12 inches; and giving cause convulsions and/or death in a very short
the victim small sips of cool water, approximately period of time. The victim can be placed in a tub
4 ounces every 15 minutes if the victim is alert of cool water, or the skin can be sponged with
and conscious. If the victim vomits, develops cool water. Ice or cold packs can be placed on the
shock, or experiences respiratory distress, medi- victim’s wrists, ankles, in each axillary (armpit)
cal help should be obtained immediately. area, and in the groin. Be alert for signs of shock
Heat stroke is caused by prolonged expo- at all times. Obtain medical help immediately.
sure to high temperatures. It is a medical emer- After victims have recovered from any con-
gency. The body is unable to eliminate the excess dition caused by heat exposure, they must
heat, and internal body temperature rises to be warned to avoid abnormally warm or hot tem-
105°F (40.6°C) or higher. Normal body defenses peratures for several days. They should also be
such as the sweating mechanism no longer func- encouraged to drink sufficient amounts of water
tion. Signs and symptoms in addition to the high and/or electrolyte solutions.
body temperature include red, hot, and dry skin.
The pulse is usually rapid, but may remain strong. STUDENT: Go to the workbook and complete
The victim may lose consciousness. Treatment is the assignment sheet for 16:7, Providing First Aid
geared primarily toward ways of cooling the body for Heat Exposure. Then return and continue with
quickly, because a high body temperature can the procedure.
PROCEDURE 16:7
tion may also be obtained directly from
Providing First Aid the victim or from observers. If the vic-
for Heat Exposure tim has been exposed to heat or has
been exercising strenuously, and is com-
Equipment and Supplies plaining of muscular pain or spasm, he
or she is probably experiencing heat
Water, wash cloths or small towels cramps. If the victim has close-to-nor-
mal body temperature but has pale and
Procedure clammy skin, is perspirating excessively,
and complains of nausea, headache,
1. Follow the priorities of care, if indi- weakness, dizziness, or fatigue, he or
cated: she is probably experiencing heat
a. Check the scene. Move the victim exhaustion. If body temperature is high
only if absolutely necessary. (105°F, or 40.6°C, or higher); skin is red,
dry, and hot; and the victim is weak or
b. Check the victim for consciousness unconscious, he or she is experiencing
and breathing. heat stroke.
c. Call emergency medical services 3. If the victim has heat cramps:
(EMS) if necessary.
a. Use your hand to apply firm pressure
d. Provide care to the victim. to the cramped muscle(s). This helps
e. Check for bleeding. Control severe relieve the spasms.
bleeding. b. Encourage relaxation. Allow the vic-
CAUTION: If possible, wear gloves or tim to lie down in a cool area, if pos-
use a protective barrier while control- sible.
ling bleeding. c. If the victim is alert and conscious
2. Observe the victim closely for signs and and is not nauseated or vomiting,
symptoms of heat exposure. Informa- give him or her small sips of cool
First Aid 495
PROCEDURE 16:7
water or an electrolyte solution such CAUTION: Watch that the victim’s head
as a sport drink. Encourage the vic- is not submerged in water. If the victim
tim to drink approximately 4 ounces is unconscious, you may need assis-
every 15 minutes. tance to place him or her in the tub.
d. If the heat cramps continue or get d. If vomiting occurs, position the vic-
worse, obtain medical help. tim on his or her side. Watch for signs
of difficulty in breathing and provide
4. If the victim has heat exhaustion:
care as indicated.
a. Move the victim to a cool area, if pos-
e. Obtain medical help immediately.
sible. An air-conditioned room is
This is a life-threatening emergency.
ideal, but a fan can also help circu-
late air and cool the victim. 6. Shock can develop quickly in all victims
of heat exposure. Be alert for the signs of
b. Help the victim lie down flat on the
shock and treat as necessary.
back. Elevate the victim’s feet and
legs 12 inches. CAUTION: Obtain medical help for heat
cramps that do not subside, heat exhaus-
c. Loosen any tight clothing. Remove
tion with signs of shock or vomiting,
excessive clothing such as jackets
and all heat stroke victims as soon as
and sweaters.
possible.
d. Apply cool, wet cloths to the victim’s
7. Reassure the victim as you are providing
face.
treatment. Remain calm.
e. If the victim is conscious and is not
8. Wash hands thoroughly after providing
nauseated or vomiting, give him or
care.
her small sips of cool water or an
electrolyte solution such as a sport
drink. Encourage the victim to drink
approximately 4 ounces every 15
minutes.
f. If the victim complains of nausea Practice
and/or vomits, discontinue the water. Go to the workbook and use the
Obtain medical help. evaluation sheet for 16:7, Providing
5. If the victim has heat stroke: First Aid for Heat Exposure, to
a. Immediately move the victim to a
cool area, if at all possible.
b. Remove excessive clothing. instructor for further action.
c. Sponge the bare skin with cool water,
or place ice or cold packs on the vic-
tim’s wrists, ankles, and in the axillary
and groin areas. The victim can also Final Checkpoint Using the criteria
be placed in a tub of cool water to listed on the evaluation sheet, your
lower body temperature. instructor will grade your performance.
496 CHAPTER 16
16:8 INFORMATION
Providing First Aid
for Cold Exposure
Exposure to cold external temperatures can cause
body tissues to freeze and body processes to slow.
If treatment is not provided immediately, the vic-
tim can die. Factors such as wind velocity, amount
of humidity, and length of exposure all affect the
degree of injury.
Prolonged exposure to the cold can result in
hypothermia, a condition in which the body
temperature is less than 95°F (35°C). Elderly indi-
viduals are more susceptible to hypothermia than FIGURE 16-31 Frostbite is actual freezing of
are younger individuals (figure 16-30). Signs and tissue fluids accompanied by damage to skin and
symptoms include shivering, numbness, weak- underlying tissues. (Courtesy of Deborah Funk, MD,
ness or drowsiness, low body temperature, poor Albany Medical Center, Albany, NY)
coordination, confusion, and loss of conscious-
ness. If prolonged exposure continues, body pro- Early signs and symptoms include redness and
cesses will slow down and death can occur. tingling. As frostbite progresses, signs and symp-
Treatment consists of getting the victim to a warm toms include pale, glossy skin, white or grayish
area, removing wet clothing, slowly warming the yellow in color; blisters; skin that is cold to the
victim by wrapping in blankets or putting on dry touch; numbness; and sometimes, pain that
clothing, and, if the victim is fully conscious, giv- gradually subsides until the victim does not feel
ing warm nonalcoholic, noncaffeinated liquids any pain. If exposure continues, the victim may
by mouth. Avoid warming the victim too quickly, become confused, lethargic, and incoherent.
because rapid warming can cause dangerous Shock may develop followed by unconsciousness
heart arrhythmias. and death. First aid for frostbite is directed at
Frostbite is actual freezing of tissue fluids maintaining respirations, treating for shock,
accompanied by damage to the skin and under- warming the affected parts, and preventing fur-
lying tissues (figure 16-31). It is caused by expo- ther injury. Frequently, small areas of the body
sure to freezing or below-freezing temperatures. are affected by frostbite. Common sites include
the fingers, toes, ears, nose, and cheeks. Extreme
care must be taken to avoid further injury to areas
damaged by frostbite. Because the victim usually
does not feel pain, the part must be warmed care-
fully, taking care not to burn the injured tissue.
The parts affected may be immersed in warm
water at 100–104°F (37.8–40°C).
CAUTION: Heat lamps, hot water above
104°F (40°C), or heat from a stove or oven
should not be used. Furthermore, the parts
should not be rubbed or massaged, because
this may cause gangrene (death of the tis-
sue). Avoid opening or breaking any blisters
that form because doing so will create an
open wound. Do not allow the victim to
walk or stand if the feet, legs, or toes are
FIGURE 16-30 Elderly individuals are more affected. Dry, sterile dressings can be placed
susceptible to hypothermia than are younger between toes or fingers to prevent them
individuals. from rubbing and causing further injury.
First Aid 497
Medical help should be obtained as quickly STUDENT: Go to the workbook and complete
as possible. the assignment sheet for 16:8, Providing First Aid
Shock is frequently noted in victims exposed for Cold Exposure. Then return and continue with
to the cold. Be alert for all signs of shock and treat the procedure.
for shock as necessary.
PROCEDURE 16:8
3. Move the victim to a warm area as soon
Providing First Aid as possible.
for Cold Exposure 4. Immediately remove any wet or frozen
clothing. Loosen any tight clothing that
Equipment and Supplies decreases circulation.
Blankets, bath water and thermometer, ster- 5. Slowly warm the victim by wrapping the
ile gauze sponges victim in blankets or dressing the victim
in dry, warm clothing. If a body part is
Procedure affected by frostbite, immerse the part
in warm water measuring 100–104°F
1. Follow the priorities of care, if indi- (37.8–40°C).
cated: CAUTION: Warm a victim of hypother-
a. Check the scene. Move the victim mia slowly. Rapid warming can cause
only if absolutely necessary. heart problems or increase circulation
to the surface of the body, which causes
additional cooling of vital organs.
and breathing.
CAUTION: Do not use heat lamps, hot
water above the stated temperatures, or
(EMS) if necessary.
heat from stoves or ovens. Excessive
d. Provide care to the victim. heat can burn the victim.
e. Check for bleeding. Control severe 6. After the body part affected by frostbite
bleeding. has been thawed and the skin becomes
CAUTION: If possible, wear gloves or flushed, discontinue warming the area
use a protective barrier while control- because swelling may develop rapidly.
ling bleeding. Dry the part by blotting gently with a
towel or soft cloth. Gently wrap the part
2. Observe the victim closely for signs and in clean or sterile cloths. Use sterile
symptoms of cold exposure. Informa- gauze to separate the fingers and/or
tion may also be obtained directly from toes to prevent them from rubbing
the victim or observers. Note shivering, together.
numbness, weakness or drowsiness,
confusion, low body temperature, and CAUTION: Never rub or massage the
lethargy. Check the skin, particularly on frostbitten area, because doing so can
the toes, fingers, ears, nose, and cheeks. cause gangrene.
Suspect frostbite if any areas are pale, 7. Help the victim lie down. Do not allow
glossy, white or grayish yellow, and cold the victim to walk or stand if the legs,
to the touch, and if the victim complains feet, or toes are injured. Elevate any
of any part of the body feeling numb or injured areas.
painless.
498 CHAPTER 16
PROCEDURE 16:8
8. Observe the victim for signs of shock.
Treat for shock as necessary.
9. If the victim is conscious and is not nau-
seated or vomiting, give warm liquids to
Practice
drink. evaluation sheet for 16:8, Providing
CAUTION: Do not give beverages con- First Aid for Cold Exposure, to
taining alcohol or caffeine. Give the vic- practice this procedure. When you
tim warm broth, water, or milk. believe you have mastered this skill,
10. Reassure the victim while providing sign the sheet and give it to your
treatment. Remain calm and encourage instructor for further action.
the victim to remain calm.
11. Obtain medical help as soon as possi-
ble.
12. Wash hands thoroughly after providing listed on the evaluation sheet, your
care. instructor will grade your performance.
♦
16:9 INFORMATION pain and tenderness at the fracture site
♦ swelling and discoloration
Providing First Aid for Bone ♦ the protrusion of bone ends through the skin
and Joint Injuries ♦ the victim heard a bone break or snap or felt a
Injuries to bones and joints are common in acci- grating sensation (crepitation)
dents and falls. A variety of injuries can occur to ♦ abnormal movements within a part of the
bones and joints. Such injuries sometimes occur body
together; other times, these injuries occur by
themselves. Examples of injuries to bones and Basic principles of treatment for fractures
joints are fractures, dislocations, sprains, and include:
strains. ♦ maintain respirations
♦ treat for shock
FRACTURES ♦ keep the broken bone from moving
♦ prevent further injury.
A fracture is a break in a bone. A closed, or sim-
ple, fracture is a bone break that is not accompa- ♦ use devices such as splints and slings to pre-
nied by an external or open wound on the skin. A vent movement of the injured part.
compound, or open, fracture is a bone break that ♦ obtain medical help whenever a fracture is
is accompanied by an open wound on the skin. evident or suspected
The types of fractures are discussed in Chapter
7:4 and shown in figure 7-22.
Signs and symptoms of fractures can vary. DISLOCATIONS
Not all signs and symptoms will be present in
every victim. Common signs and symptoms A dislocation is when the end of a bone is either
include: displaced from a joint or moved out of its normal
position within a joint. This injury is frequently
♦ deformity accompanied by a tearing or stretching of liga-
♦ limited motion or loss of motion ments, muscles, and other soft tissue.
First Aid 499
Signs and symptoms that may occur include: strain include sudden pain, swelling, and/or
bruising.
♦ deformity
Basic principles of first aid treatment for a
♦ limited or abnormal movement strain include:
♦ swelling
♦ Encourage the victim to rest the affected mus-
♦ discoloration cle while providing support
♦ pain and tenderness ♦ Recommend bedrest with a backboard under
♦ a shortening or lengthening of the affected the mattress for a strained back
arm or leg
♦ Apply cold applications to reduce the swell-
First aid for dislocations is basically the same ing
as that for fractures. No attempt should be made ♦ After the swelling decreases, apply warm, wet
to reduce the dislocation (that is, replace the applications because warmth relaxes the mus-
bone in the joint). The affected part must be cles; different types of cold and heat packs are
immobilized in the position in which it was available (figure 16-32)
found. Immobilization is accomplished by using
splints and/or slings. Movement of the injured ♦ Obtain medical help for severe strains and all
part can lead to additional injury to nerves, blood back injuries
vessels, and other tissue in the area. Obtain med-
ical help immediately.
SPLINTS
SPRAINS Splints are devices that can be used to immobi-
lize injured parts when fractures, dislocations,
A sprain is an injury to the tissues surrounding a and other similar injuries are present or sus-
joint; it usually occurs when the part is forced pected. Many commercial splints are available,
beyond its normal range of movement. Liga- including inflatable, or air, splints, padded
ments, tendons, and other tissues are stretched boards, and traction splints. Splints can also be
or torn. Common sites for sprains include the made from cardboard, newspapers, blankets, pil-
ankles and wrists. lows, boards, and other similar materials. Some
Signs and symptoms of a sprain include swell- basic principles regarding the use of splints are:
ing, pain, discoloration, and sometimes, impaired ♦ Splints should be long enough to immobilize
motion. Frequently, sprains resemble fractures or the joint above and below the injured area
dislocations. If in doubt, treat the injury as a frac- (figure 16-33). By preventing movement in
ture. these joints, the injured bone or area is held in
First aid for a sprain includes: position and further injury is prevented.
♦ Apply a cold application to decrease swelling
and pain
♦ Elevate the affected part
♦ Encourage the victim to rest the affected part
♦ Apply an elastic bandage to provide support
for the affected area but avoid stretching the
bandage too tightly
♦ Obtain medical help if swelling is severe or if
there is any question of a fracture
STRAINS
A strain is the overstretching of a muscle; it is FIGURE 16-32 Disposable heat and cold packs
caused by overexertion or lifting. A frequent site contain chemicals that must be activated before
for strains is the back. Signs and symptoms of a using.
500 CHAPTER 16
♦ Pneumatic splints are available in various sizes

and shapes for different parts of the arms and
legs. Care must be taken to avoid any unnec-
essary movement while the splint is being
positioned. There are two main types of pneu-
matic splints: air (inflatable) and vacuum
(deflatable).
If an air splint is positioned over a fracture
site, air pressure is used to inflate the splint
(figure 16-34A). Some air splints have nozzles;
these splints are inflated by blowing into the
nozzles. Other air splints require the use of
pressurized material in cans, while still others
are inflated with cool air from a refrigerant
solution. The coldness reduces swelling. Care
must be taken to avoid overinflating air splints.
To test whether the splint is properly inflated,
use a thumb to apply slight pressure to the
splint; an indentation mark should result.
Vacuum pneumatic splints are deflated
after being positioned over a fracture site. Air is
removed from the splint with a hand pump or
suction pump until the splint molds to the
FIGURE 16-33 Splints should be long enough to fracture site to provide support (figure 16-34B).
immobilize the joint above and below the injured Care must be taken to avoid overdeflation of
area. the splint. A pulse site below the splint should
be checked to make sure the splint is not
applying too much pressure and cutting off
circulation.
♦ Splints should be padded, especially at bony
areas and over the site of injury. Cloths, thick ♦ Traction splints are special devices that pro-
dressings, towels, and similar materials can be vide a pulling or traction effect on the injured
used as padding. bone. They are frequently used for fractures of
the femur, or thigh bone.
♦ Strips of cloth, roller gauze, triangular ban-
dages folded into bands or strips, and similar
materials can be used to tie splints in place.
♦ Splints must be applied so that they do not
put pressure directly over the site of injury.
♦ If an open wound is present, use a sterile
dressing to apply pressure and control bleed-
ing.
CAUTION: Wear gloves or use a protective
barrier while controlling bleeding to avoid
contamination from the blood.
CAUTION: Leave the dressing in place, and
apply the splint in such a way that it does
not put pressure on the wound.
♦ Never make any attempt to replace broken
bones or reduce a fracture or dislocation. Do FIGURE 16-34A Some air splints are inflated by
not move the victim. Splint wherever you find blowing into a nozzle. Care must be taken to avoid
the victim. overinflating this type of splint.
First Aid 501
FIGURE 16-34B Vacuum pneumatic splints are

deflated until the splint molds to the fracture site to
provide support. FIGURE 16-35 Commercial slings usually have a
series of straps that extend around the neck and/or
thoracic region.
CAUTION: Only persons specifically trained
in the application of traction splints should
apply them. elevating the hand is to promote circulation,
prevent swelling (edema), and decrease pain.
♦ After a splint is applied, it is essential to note
the circulation and the effects on the nerve ♦ Circulation in the limb and nerve supply to the
endings of the skin below the splint to make limb must be checked frequently. Specifically,
sure the splint is not too tight. Check skin tem- check for skin temperature (should be warm if
perature (it should be warm to the touch), skin circulation is good), skin color (blue or very pale
color (pale or blue indicates poor circulation), indicates poor circulation), swelling (edema),
swelling or edema, numbness or tingling, and amount of pain, and tingling or numbness. Nail
pulse, if possible. beds can also be used to check circulation.
When the nail beds are pressed slightly, they
CAUTION: If any signs of impaired circula- blanch (turn white). If circulation is good, the
tion or impaired neurological status are pink color should return to the nail beds imme-
present, immediately loosen the ties hold- diately after the pressure is released.
ing the splint.
♦ If a sling is being applied because of a sus-
pected fracture to the bone, extreme care must
SLINGS be taken to move the injured limb as little as
possible while the sling is being applied. The
Slings are available in many different forms. Com- victim can sometimes help by holding the
mercial slings usually have a series of straps that injured limb in position while the sling is
extend around the neck and/or thoracic (chest) slipped into place.
region (figure 16-35). A common type of sling ♦ If a triangular bandage is used, care must be
used for first aid is the triangular bandage. Slings taken so that the knot tied at the neck does not
are usually used to support the arm, hand, fore- press against a bone. The knot should be tied
arm, and shoulder. They may be used when casts to either side of the spinal column. Place gauze
are in place. In addition, they are also used to or padding under the knot of the sling to pro-
provide immobility if a fracture of the arm or tect the skin.
shoulder is suspected. Basic principles to observe
♦ When shoulder injuries are suspected, it may
with slings include:
be necessary to keep the arm next to the body.
♦ When a sling is applied to an arm, the sling After a sling has been applied, another ban-
should be positioned in such a way that the dage can be placed around the thoracic region
hand is higher than the elbow. The purpose of to hold the arm against the body.
502 CHAPTER 16
Injuries to bones and/or joints usually

NECK AND SPINE involve a great deal of anxiety, pain, and dis-
INJURIES comfort, so constantly reassure the victim.
Encourage the victim to relax, and position the
Injuries to the neck or spine are the most danger- victim as comfortably as possible. Advise the vic-
ous types of injuries to bones and joints. tim that medical help is on the way. First aid mea-
sures are directed toward relieving the pain as
CAUTION: If a victim who has such injuries much as possible.
is moved, permanent damage resulting in Obtain medical help for all victims of bone or
paralysis can occur. If at all possible, avoid joint injuries. The only definite diagnosis of a
any movement of a victim with neck or spi- closed fracture is an X-ray of the area. Whenever
nal injuries. Wait until a backboard, cervical a fracture and/or dislocation is suspected, treat
collar, and adequate help for transfer is the victim as though one of these injuries has
available. occurred.
SUMMARY STUDENT: Go to the workbook and complete

Victims with injuries to bones and/or joints also the assignment sheet for 16:9, Providing First Aid
experience shock. Always be alert for signs of for Bone and Joint Injuries. Then return and con-
shock and treat as needed. tinue with the procedure.
PROCEDURE 16:9
CAUTION: If neck or spinal injuries are
Providing First Aid suspected, avoid any movement of the
for Bone and Joint victim unless movement is necessary to
Injuries save the victim’s life.
Equipment and Supplies and breathing.
Blankets, splints of various sizes, air or inflat-
(EMS) if necessary.
able splints, triangular bandages, strips of
cloth or roller gauze, disposable gloves d. Provide care to the victim.
e. Control severe bleeding. If an open
Procedure wound accompanies a fracture, take
care not to push broken bone ends
1. Follow the priorities of care, if indi- into the wound.
cated:
CAUTION: If possible, wear gloves or
a. Check the scene. Move the victim use a protective barrier while control-
only if absolutely necessary. If the ling bleeding.
victim must be moved from a dan-
gerous area, pull in the direction of 2. Observe for signs and symptoms of a
the long axis of the body (that is, from fracture, dislocation, or joint injury.
the head or feet). If at all possible, tie Note deformities (such as a shortening
an injured leg to the other leg or or lengthening of an extremity), limited
secure an injured arm to the body motion or loss of motion, pain, tender-
before movement. ness, swelling, discoloration, and bone
First Aid 503
PROCEDURE 16:9
fragments protruding through the skin. because the bandage may cut off or
Also, the victim may state that he or she interfere with circulation. If splints
heard a bone snap or crack, or may com- are long, three to five ties may be
plain of a grating sensation. required. Tie the strips above and
below the upper joint and above and
3. Immobilize the injured part to prevent
below the lower joint. An additional
movement.
tie should be placed in the center
CAUTION: Do not attempt to straighten region of the splint.
a deformity, replace broken bone ends,
f. Avoid any unnecessary movement of
or reduce a dislocation. Avoid any
the injured area while splints are
unnecessary movement of the injured
being applied. If possible, have
part. If a bone injury is suspected, treat
another individual support the area
the victim as though a fracture or dislo-
while you are applying the splints.
cation has occurred. Use splints or slings
to immobilize the injury. 5. To apply air (inflatable) splints:
4. To apply splints: a. Obtain the correct splint for the
injured part.
a. Obtain commercial splints or impro-
vise splints by using blankets, pil- NOTE: Most air splints are available for
lows, newspapers, boards, cardboard, full arm, lower arm, wrist, full leg, lower
or similar supportive materials. leg, and ankle/foot.
b. Make sure that the splints are long b. Some air splints have zippers for eas-
enough to immobilize the joint both ier application, but others must be
above and below the injury. slipped into position on the victim. If
the splint has a zipper, position the
c. Position the splints, making sure that
open splint on the injured area, tak-
they do not apply pressure directly at
ing care to avoid any movement of
the site of injury. Two splints are usu-
the affected part. Use your hand to
ally used. However, if a pillow, blan-
support the injured area. Close the
ket, or similar item is used, one such
zipper. If the splint must be slipped
item can be rolled around the area to
into position, slide the splint onto
provide support on all sides.
your arm first. Then hold the injured
d. Use thick dressings, cloths, towels, or leg or arm and slide the splint from
other similar materials to pad the your arm to the victim’s injured
splints. Make sure bony areas are extremity. This technique prevents
protected. Avoid direct contact unnecessary movement.
between the splint material and the
c. Inflate the splint. Many splints are
skin.
inflated by blowing into the nozzle.
NOTE: Many commercial splints are Others require the use of a pressure
already padded. However, additional solution in a can. Follow instructions
padding is often needed to protect the provided by the manufacturer of the
bony areas. splint.
e. Use strips of cloth, triangular ban- d. Check to make sure that the splint is
dages folded into strips, roller gauze, not overinflated. Use your thumb to
or other similar material to tie or press a section of the splint. Your
anchor the splints in place. The use thumb should leave a slight indenta-
of elastic bandage is discouraged tion if the splint is inflated correctly.
504 CHAPTER 16
PROCEDURE 16:9
6. To apply a sling, follow the manufactur- d. Use a square knot to tie the two ends
er’s instructions for commercial slings. together near the neck. Make sure
To use a triangular bandage for a sling the knot is not over a bone. Tie it to
(figure 16-36), proceed as follows: either side of the spinal column.
Place gauze or padding between the
a. If possible, obtain the help of another
knot and the skin. Make sure the
individual to support the injured arm
hand is elevated 5–6 inches above
while the sling is being applied.
the elbow.
Sometimes, the victim can hold the
injured arm in place. e. The point of the bandage is now near
the elbow. Bring the point forward,
b. Place the long straight edge of the tri-
fold it, and pin it to the front of the
angular bandage on the uninjured
sling. If no pin is available, coil the
side. Allow one end to extend over
end and tie it in a knot.
the shoulder of the uninjured arm.
The other end should hang down in CAUTION: If you use a pin, put your
front of the victim’s chest. The short hand between the pin and the victim’s
edge of the triangle should extend skin while inserting the pin.
back and under the elbow of the
f. Check the position of the sling. The
injured arm.
fingers of the injured hand should
CAUTION: Avoid excessive movement extend beyond the edge of the trian-
of the injured limb while positioning the gular bandage. In addition, the hand
sling. should be slightly elevated to prevent
swelling (edema).
c. Bring the long end of the bandage up
and over the shoulder of the injured g. If a shoulder injury is suspected, it
arm. may be necessary to secure the arm
close to the body. Apply a large ban-
dage around the thoracic region to
stabilize the shoulder joint (figure
16-37).
7. After splints and/or slings have been
applied, check for signs of impaired cir-
culation. Skin color should be pink. A
FIGURE 16-37 If a shoulder injury is sus-

FIGURE 16-36 Steps for applying a triangu- pected, use a long bandage to secure the arm
lar bandage as a sling. against the body to stabilize the shoulder joint.
First Aid 505
PROCEDURE 16:9
pale or cyanotic (bluish) color is a sign CAUTION: Avoid any movement if a
of poor circulation. The skin should be neck or spinal injury is suspected.
warm to the touch. Swelling can indi-
11. Reassure the victim while providing first
cate poor circulation. If the victim com-
aid. Try to relieve the pain by carefully
plains of pain or pressure from the
positioning the injured part, avoiding
splints and/or slings, or of numbness or
unnecessary movement, and applying
tingling in the area below the splints/
cold.
sling, circulation may be impaired.
Slightly press the nail beds on the foot 12. Obtain medical help as quickly as pos-
or hand so they temporarily turn white. sible.
If circulation is good, the pink color will 13. Wash hands thoroughly after providing
return to the nail beds immediately after care.
pressure is released. If you note any
signs of impaired circulation, loosen the
splints and/or sling immediately.
8. Watch for signs of shock in any victim
with a bone and/or joint injury. Remem-
ber, inadequate blood flow is the main
cause of shock. Watch for signs of Practice
impaired circulation, such as a cyanotic Go to the workbook and use the
(bluish) tinge around the lips or nail evaluation sheet for 16:9, Providing
beds. Treat for shock, as necessary. First Aid for Bone and Joint Injuries,
9. If medical help is delayed, cold applica- to practice this procedure. When you
tions such as cold compresses or an ice believe you have mastered this skill,
bag can be used on the injured area to sign the sheet and give it to your
decrease swelling. instructor for further action.
CAUTION: To prevent injury to the skin,

make sure that the ice bag is covered
with a towel or other material.
10. Place the victim in a comfortable posi- Final Checkpoint Using the criteria
tion, but avoid any unnecessary move- listed on the evaluation sheet, your
ment. instructor will grade your performance.
16:10 INFORMATION EYE INJURIES

Providing First Aid for Specific Any eye injury always involves the danger of
Injuries vision loss, especially if treated incorrectly. In
most cases involving serious injury to the eyes, it
Although treatment for burns, bleeding, wounds, is best not to provide major treatment. Obtaining
poisoning, and fractures is basically the same for medical help, preferably from an eye specialist, is
all regions of the body, injuries to specific body a top priority of first aid care.
parts require special care. Examples of these parts
are the eyes, ears, nose, brain, chest, abdomen, ♦ Foreign objects such as dust, dirt, and similar
and genital organs. small particles frequently enter the eye. These
506 CHAPTER 16
objects cause irritation and can scratch the

eye or become embedded in the eye tissue.
Signs and symptoms include redness, a burn-
ing sensation, pain, watering or tearing of the
eye, and/or the presence of visible objects in
the eye. If the foreign body is floating freely,
prevent the victim from rubbing the eye, wash
your hands thoroughly, and gently draw the
upper lid down over the lower lid. This stimu-
lates the formation of tears. The proximity of
the lids also creates a wiping action, which
may remove the particle. If this does not
remove the foreign body, use your thumb and
forefinger to grasp the eyelashes and gently FIGURE 16-38 A cup can be used to stabilize an
raise the upper eyelid. Tell the victim to look object impaled in the eye and to prevent it from
down and tilt his or her head toward the moving.
injured side. Use water to gently flush the eye
or use the corner of a piece of sterile gauze to
gently remove the object.
CAUTION: If this does not remove the object
EAR INJURIES
or if the object is embedded, make no Injuries to the ear can result in rupture or perfo-
attempt to remove it. ration of the eardrum. These injuries also require
Apply a dry, sterile dressing and obtain medical care. Treatment for specific types of ear
medical help for the victim. Serious injury can injuries is as follows:
occur if any attempt is made to remove an
object embedded in the eye tissue. ♦ Wounds of the ear frequently result in torn or
detached tissue. Apply sterile dressings with
♦ Blows to the eye from a fist, accident, or explo- light pressure to control bleeding.
sion may cause contusions or black eyes as a
CAUTION: If possible, wear gloves or use a
result of internal bleeding and torn tissues
protective barrier while controlling bleed-
inside the eye. Because this can lead to loss of
ing.
vision, the victim should be examined as soon
Save any torn tissue and wrap it in gauze
as possible by an eye specialist. Apply sterile
moistened with cool sterile water or sterile
dressings or an eye shield, keep the victim
normal saline solution. Put the gauze wrapped
lying flat, and obtain medical help. It is some-
tissue in a plastic bag to keep it cool and moist.
times best to cover both eyes to prevent invol-
Send the torn tissue to the medical facility
untary movement of the injured eye.
along with the victim.
♦ Penetrating injuries that cut the eye tissue are NOTE: If sterile water is not available, use
extremely dangerous.
cool, clean water.
CAUTION: If an object is protruding from the ♦ Keep the victim lying flat, but raise his or her
eye, make no attempt to remove the object. head (if no other conditions prohibit raising
Rather, support it by loosely applying dress- the head).
ings. A paper cup with a hole cut in the bot-
tom can also be used to stabilize the object ♦ If the eardrum is ruptured or perforated, place
and prevent it from moving (figure 16-38). sterile gauze loosely in the outer ear canal. Do
Apply dressings to both eyes to prevent not allow the victim to hit the side of the head
involuntary movement of the injured eye. in an attempt to restore hearing. Do not put
Avoid applying pressure to the eye while apply- any liquids into the ear. Obtain medical help
ing the dressings. Keep the victim lying flat on for the victim.
his or her back to prevent fluids from draining ♦ Clear or blood-tinged fluid draining from the
out of the eye. Obtain medical help immedi- ear can be a sign of skull or brain injury. Allow
ately. the fluid to flow from the ear. Keep the victim
First Aid 507
lying down. If possible, turn the victim on his more frightening than they are serious. Nose-
or her injured side and elevate the head and bleeds can also be caused by change in altitude,
shoulders slightly to allow the fluid to drain. strenuous activity, high blood pressure, and rup-
Obtain medical help immediately and report ture of small blood vessels after a cold. Treatment
the presence and description of the fluid. for a nosebleed includes:
CAUTION: Wear gloves or use a protective ♦ Keep the victim quiet and remain calm.
barrier to avoid skin contact with fluid ♦ If possible, place the victim in a sitting posi-
draining from the ear. tion with the head leaning slightly forward.
♦ Apply pressure to control bleeding by pressing
HEAD OR SKULL the bleeding nostril toward the midline. If
both nostrils are bleeding, press both nostrils
INJURIES toward the midline.
Wounds or blows to the head or skull can result in NOTE: If both nostrils are blocked, tell the
injury to the brain. Again, it is important to obtain victim to breathe through the mouth.
medical help as quickly as possible for the vic- CAUTION: Wear gloves or use a protective
tim. barrier to avoid contamination from blood.
♦ Signs and symptoms of brain injury include ♦ If application of pressure against the midline
clear or blood-tinged cerebrospinal fluid or septum does not stop the bleeding, insert a
draining from the nose or ears, loss of con- small piece of gauze in the nostril and then
sciousness, headache, visual disturbances, apply pressure on the outer surface of the nos-
pupils unequal in size, muscle paralysis, tril. Be sure to leave a portion of the gauze
speech disturbances, convulsions, and nausea extending out of the nostril so that the pack-
and vomiting. ing can be removed later.
♦ Keep the victim lying flat and treat for shock. CAUTION: Do not use cotton balls because
If there is no evidence of neck or spinal injury, the fibers will shed and stick.
raise the victim’s head slightly by supporting
♦ Apply a cold compress to the bridge of the
the head and shoulders on a small pillow or a
nose. A covered ice pack or a cold, wet cloth
rolled blanket or coat.
can be used.
♦ Watch closely for signs of respiratory distress ♦ If the bleeding does not stop or a fracture of
and provide artificial respiration as needed.
the nose is suspected, obtain medical assis-
♦ Make no attempt to stop the flow of fluid. tance. If a person has repeated nosebleeds, a
Loose dressings can be positioned to absorb referral for medical attention should be made.
the flow. Nosebleeds can indicate an underlying condi-
CAUTION: Wear gloves or use a protective tion that requires medical care and treatment,
barrier to avoid contamination from the such as high blood pressure.
cerebrospinal fluid.
♦ Do not give the victim any liquids. If the victim
complains of excessive thirst, use a clean, cool, CHEST INJURIES
wet cloth to moisten the lips, tongue, and
inside of the mouth. Injuries to the chest are usually medical emer-
gencies because the heart, lungs, and major blood
♦ If the victim loses consciousness, note how vessels may be involved. Chest injuries include
long the victim is unconscious and report this sucking chest wounds, penetrating wounds, and
to the emergency rescue personnel. crushing injuries. In all cases, obtain medical
help immediately.
NOSE INJURIES ♦ Sucking chest wound: This is a deep, open

chest wound that allows air to flow directly in
Injuries to the nose frequently cause a nosebleed, and out with breathing. The partial vacuum
also called an epistaxis. Nosebleeds are usually that is usually present in the pleura (sacs sur-
508 CHAPTER 16
rounding the lungs) is destroyed, causing the comfortable position, maintain respirations,
lung on the injured side to collapse. Immedi- and obtain medical help immediately.
ate medical help must be obtained. An airtight ♦ Crushing chest injuries: These injuries are
dressing must be placed over the wound to caused in vehicular accidents or when heavy
prevent air flow into the wound. Aluminum objects strike the chest. Fractured ribs and
foil, plastic wrap, or other nonporous material damage to the lungs and/or heart can occur.
should be used to cover the wound. Tape or a Place the victim in a comfortable position
bandage can be used to hold the nonporous and, if possible, elevate the head and shoul-
material in place on three sides. The fourth ders to aid breathing. If an injury to the neck
side should be left loose to allow air to escape or spine is suspected, avoid moving the vic-
when the victim exhales. When the victim tim. Obtain medical help immediately.
inhales, the negative pressure of inspirations
will draw the dressing against the wound to
create an airtight seal. Maintain an open air-
way (through the nose or mouth) and provide
artificial respiration as needed. If possible,
ABDOMINAL INJURIES
position the victim on his or her injured side Abdominal injuries can damage internal organs
and elevate the head and chest slightly. This and cause bleeding in major blood vessels. The
allows the uninjured lung to expand more intestines and other abdominal organs may pro-
freely and prevents pressure on the uninjured trude from an open wound. Medical help must
lung from blood and damaged tissue. be obtained immediately; bleeding, shock, and
♦ Penetrating injuries to the chest: These injuries organ damage can lead to death in a short period
can result in sucking chest wounds or damage of time.
to the heart and blood vessels. If an object (for ♦ Signs and symptoms include severe abdomi-
example, a knife) is protruding from the chest, nal pain or tenderness, protruding organs,
do not attempt to remove the object. If possi- open wounds, nausea and vomiting (particu-
ble, immobilize the object by placing dress- larly of blood), abdominal muscle rigidity, and
ings around it and taping the dressings in symptoms of shock.
position (figure 16-39). Place the victim in a
♦ Position the victim flat on his or her back.
Place a pillow or rolled blanket under the
knees to bend the knees slightly. This helps
relax the abdominal muscles. Elevate the head
and shoulders slightly to aid breathing.
♦ Remove clothing from around the wound or
protruding organs. Use a large sterile dressing
moistened with sterile water or normal saline
solution to cover the area. If sterile water or
normal saline is not available, use warm tap
water to moisten the dressings. Cover the
dressings with plastic wrap, if available, to
keep the dressings moist. Then cover the
dressings with aluminum foil or a folded towel
to keep the area warm.
CAUTION: Make no attempt to reposition

protruding organs.
♦ Avoid giving the victim any fluids or food. If
FIGURE 16-39 Immobilize an object protruding the victim complains of excessive thirst, use a
from the chest by placing dressings around the cool, wet cloth to moisten the lips, tongue,
object and taping the dressings in place. and inside of the mouth.
First Aid 509
the torn tissue to the medical facility along

INJURIES TO GENITAL with the victim.
ORGANS ♦ Use a covered ice pack or other cold applica-
tions to decrease bleeding and relieve pain.
Injuries to genital organs can result from falls,
♦ Obtain medical help.
blows, or explosions. Zippers catching on geni-
tals and other accidents sometimes bruise the
genitals. Because injuries to the genitals may
cause severe pain, bleeding, and shock, medical
SUMMARY
help is required. Basic principles of first aid Shock frequently occurs in victims with specific
include the following: injuries to the eyes, ears, chest, abdomen, or
other vital organs. Be alert for the signs of shock
♦ Control severe bleeding by using a sterile (or and immediately treat all victims.
clean) dressing to apply direct pressure to the Most of the specific injuries discussed in
area. this section result in extreme pain for the
CAUTION: Wear gloves or use a protective victim. It is essential that you reassure the victim
barrier to avoid contamination from blood. constantly and encourage the victim to relax as
♦ Treat the victim for shock. much as possible. Direct first aid care toward pro-
viding as much relief from pain as possible.
♦ Do not remove any penetrating or inserted
objects.
♦ Save any torn tissue and wrap it in gauze STUDENT: Go to the workbook and complete
moistened with cool sterile water or sterile the assignment sheet for 16:10, Providing First Aid
normal saline. Put the gauze-wrapped tissue for Specific Injuries. Then return and continue
in a plastic bag to keep it cool and moist. Send with the procedure.
PROCEDURE 16:10
Providing First Aid
e. Check for bleeding. Control severe
for Specific Injuries bleeding.
Equipment and Supplies CAUTION: If possible, wear gloves or

Blankets, pillows, dressings, bandages, tape, ling bleeding.
aluminum foil or plastic wrap, eye shields or
2. Observe the victim closely for signs and
sterile dressings, sterile water, disposable
symptoms of specific injuries. Do a sys-
gloves
tematic examination of the victim.
Always have a reason for everything you
Procedure do. Explain what you are doing to the
victim and/or observers.
1. Follow the priorities of care, if indi-
cated: 3. If the victim has an eye injury, proceed
as follows:
a. Check the scene. Move the victim
only if absolutely necessary. a. If the victim has a free-floating parti-
cle or foreign body in the eye, warn
b. Check the victim for consciousness the victim not to rub the eye. Wash
and breathing. your hands thoroughly to prevent
c. Call emergency medical services infection. Gently grasp the upper eye-
(EMS), if necessary. lid and draw it down over the lower
510 CHAPTER 16
PROCEDURE 16:10
eyelid. If this does not remove the in gauze moistened with cool, sterile
object, use your thumb and forefin- water or normal saline solution.
ger to grasp the eyelashes and gently Place the gauze-wrapped tissue in a
raise the upper eyelid. Tell the victim plastic bag. Send the torn tissue to
to look down and tilt his or her head the medical facility along with the
slightly to the injured side. Use water victim.
to gently flush the eye or use the cor-
NOTE: If sterile water is not available,
ner of a piece of sterile gauze to gently
use cool, clean water.
remove the object. If this does not
remove the object or if the object is c. If a rupture or perforation of the ear-
embedded, proceed to step b. drum is suspected or evident, place
sterile gauze loosely in the outer ear
b. If an object is embedded in the eye,
canal. Caution the victim against hit-
make no attempt to remove it. Rather,
ting the side of the head to restore
apply a dry, sterile dressing to loosely
hearing. Obtain medical help.
cover the eye. Obtain medical help.
d. If cerebrospinal fluid is draining from
c. If an eye injury has caused a contu-
the ear, make no attempt to stop the
sion, a black eye, internal bleeding,
flow of the fluid. If no neck or spinal
and/or torn tissue in the eye, apply
injury is suspected, turn the victim
sterile dressings or eye shields to both
on his or her injured side and slightly
eyes. Keep the victim lying flat. Obtain
elevate the head and shoulders to
medical help.
allow the fluid to drain. A dressing
NOTE: Both eyes are covered to prevent may be positioned to absorb the flow.
involuntary movement of the injured Obtain medical help immediately.
eye.
CAUTION: Wear gloves or use a protec-
d. If an object is protruding from the tive barrier to prevent contamination
eye, make no attempt to remove the from the cerebrospinal fluid.
object. If possible, support the object
5. If the victim has a brain injury:
in position by loosely placing dress-
ings around it. A paper cup with the a. Keep the victim lying flat. Treat for
bottom removed can also be used to shock. If there is no evidence of a
surround and prevent any move- neck or spinal injury, place a small
ment of the object. Apply dressings pillow or a rolled blanket or coat
to the uninjured eye to prevent move- under the victim’s head and shoul-
ment of the injured eye. Keep the vic- ders to elevate the head slightly.
tim lying flat. Obtain medical help CAUTION: Never position the victim’s
immediately. head lower than the rest of the body.
4. If the victim has an ear injury: b. Watch closely for signs of respiratory
a. Control severe bleeding from an ear distress. Provide artificial respiration
wound by using a sterile dressing to if needed.
apply light pressure. NOTE: Remove the pillow if artificial
CAUTION: Wear gloves or use a protec- respiration is given.
tive barrier to prevent contamination c. If cerebrospinal fluid is draining from
from the blood. the ears, nose, and/or mouth, make
b. If any tissue has been torn from the no attempt to stop the flow. Position
ear, preserve the tissue by placing it dressings to absorb the flow.
First Aid 511
PROCEDURE 16:10
CAUTION: Wear gloves or use a protec- f. If the bleeding does not stop, a frac-
tive barrier to prevent contamination ture is suspected, or if the victim has
from the cerebrospinal fluid. repeated nosebleeds, obtain medical
help.
d. Avoid giving the victim any fluids by
mouth. If the victim complains of NOTE: Nosebleeds can indicate a seri-
excessive thirst, use a cool, wet cloth ous underlying condition that requires
to moisten the lips, tongue, and medical attention, such as high blood
inside of the mouth. pressure.
e. If the victim is unconscious, note for 7. If the victim has a chest injury:
how long and report this information
a. If the wound is a sucking chest
to the emergency rescue personnel.
wound, apply a nonporous dressing.
f. Obtain medical help as quickly as Use plastic wrap or aluminum foil to
possible. create an airtight seal. Use tape on
three sides to hold the dressing in
6. If the victim has a nosebleed:
place. Leave the fourth side loose to
a. Try to keep the victim calm. Remain allow excess air to escape when the
calm yourself. victim exhales (figure 16-40).
b. Position the victim in a sitting posi- b. Maintain an open airway. Constantly
tion, if possible. Lean the head for- be alert for signs of respiratory dis-
ward slightly. If the victim cannot sit tress. Provide artificial respiration as
up, slightly elevate the head. needed.
c. Apply pressure by pressing the c. If there is no evidence of a neck or
nostril(s) toward the midline. Con- spinal injury, position the victim with
tinue applying pressure for at least 5 his or her injured side down. Slightly
minutes and longer if necessary to elevate the head and chest by placing
control the bleeding. small pillows or blankets under the
NOTE: If both nostrils are bleeding and victim.
must be pressed toward the midline, tell
the victim to breathe through the
mouth.
CAUTION: Wear gloves or use a protec-
tive barrier to prevent contamination
from the blood.
d. If application of pressure does not
control the bleeding, insert gauze
into the bleeding nostril, taking care
to allow some of the gauze to hang
out. Then apply pressure again by
pushing the nostril toward the mid-
line.
e. Apply cold compresses to the bridge
of the nose. Use cold, wet cloths or a FIGURE 16-40 An airtight dressing is used to
covered ice bag. cover a sucking chest wound. It is taped on
three sides. The fourth side is left open to allow
excess air to escape when the victim exhales.
512 CHAPTER 16
PROCEDURE 16:10
d. If an object is protruding from the b. Position the victim flat on the back.
chest, make no attempt to remove it. Separate the legs to prevent pressure
If possible, immobilize the object on the genital area.
with dressings, and tape around it.
c. If any tissue is torn from the area,
e. Obtain medical help immediately for preserve the tissue by wrapping it in
all chest injuries. gauze moistened with cool, sterile
water or normal saline solution. Put
8. If the victim has an abdominal injury:
the gauze-wrapped tissue in a plastic
a. Position the victim flat on the back. bag and send it to the medical facility
Place a small pillow or a rolled blan- along with the victim.
ket or coat under the victim’s knees
d. Apply cold compresses such as cov-
to flex them slightly. Elevate the head
ered ice bags to the area to relieve
and shoulders to aid breathing. If
pain and reduce swelling.
movement of the legs causes pain,
leave the victim lying flat. e. Obtain medical help for the victim.
b. If abdominal organs are protruding 10. Be alert for the signs of shock in all vic-
from the wound, make no attempt to tims. Treat for shock immediately.
reposition the organs. Remove cloth-
11. Constantly reassure all victims while
ing from around the wound or pro-
providing care. Remain calm. Encour-
truding organs. Use a sterile dressing
age the victim to relax as much as pos-
that has been moistened with sterile
sible.
water or normal saline solution to
cover the area. If sterile water or nor- 12. Always obtain medical help as quickly
mal saline is not available, use warm as possible. Shock, pain, and injuries to
tap water to moisten the dressings. vital organs can cause death in a very
short period of time.
c. Cover the dressing with plastic wrap,
if available, to keep the dressing 13. Wash hands thoroughly after providing
moist. Then apply a folded towel or care.
aluminum foil to keep the area
warm.
d. Avoid giving the victim any fluids or
food. If the victim complains of
excessive thirst, use a cool, wet cloth
Practice
to moisten the lips, tongue, and evaluation sheet for 16:10,
inside of the mouth.
Providing First Aid for Specific
e. Obtain medical help immediately. Injuries, to practice this procedure.
9. If the victim has an injury to the genital When you believe you have
organs: mastered this skill, sign the sheet
and give it to your instructor for
a. Control severe bleeding by using a further action.
sterile dressing to apply direct pres-
sure.
CAUTION: Wear gloves or use a protec- Final Checkpoint Using the criteria
tive barrier to prevent contamination listed on the evaluation sheet, your
from the blood. instructor will grade your performance.
First Aid 513
16:11 INFORMATION
Providing First Aid for Sudden
Illness
The victim of a sudden illness requires first aid
until medical help can be obtained. Sudden ill-
ness can occur in any individual. At times, it is
difficult to determine the exact illness being
experienced by the victim. However, by knowing
the signs and symptoms of some major disorders,
you should be able to provide appropriate first
aid care. Information regarding a specific condi-
tion or illness may also be obtained from the vic-
tim, medical alert bracelets or necklaces, or
medical information cards. Be alert to all of these
factors while caring for the victim of a sudden ill-
ness.
HEART ATTACK
FIGURE 16-41 Severe pressure under the
A heart attack is also called a coronary throm- sternum with pain radiating to the shoulders, arms,
bosis, coronary occlusion, or myocardial infarc- neck, and jaw is a common symptom of a heart
tion. It may occur when one of the coronary attack.
arteries supplying blood to the heart is blocked. If
the attack is severe, the victim may die. If the
heart stops beating, cardiopulmonary resuscita- obtain appropriate medical assistance as soon
tion (CPR) must be started. Main facts regarding as possible.
heart attacks are as follows: ♦ After calling EMS, the American Heart
Association recommends that patients
♦ Signs and symptoms of a heart attack may
who can should take an aspirin. Aspirin keeps
vary depending on the amount of heart dam-
platelets in the blood from sticking together to
age. Severe, painful pressure under the breast-
cause a clot. However, there are legal restric-
bone (sternum) with pain radiating to the
tions to which health care providers can
shoulders, arms, neck, and jaw is a common
administer medications. Only qualified indi-
symptom (figure 16-41). The victim usually
viduals should give the victim aspirin.
experiences intense shortness of breath. The
skin, especially near the lips and nail beds,
becomes pale or cyanotic (bluish). The victim
feels very weak but is also anxious and appre-
CEREBROVASCULAR
hensive. Nausea, vomiting, diaphoresis (exces- ACCIDENT OR STROKE
sive perspiration), and loss of consciousness
may occur. A stroke is also called a cerebrovascular acci-
dent (CVA), apoplexy, or cerebral thrombosis. It is
♦ First aid for a heart attack is directed toward
caused by either the presence of a clot in a cere-
encouraging the victim to relax, placing the
bral artery that provides blood to the brain or
victim in a comfortable position to relieve
hemorrhage from a blood vessel in the brain.
pain and assist breathing, and obtaining med-
ical help. Shock frequently occurs, so provide ♦ Signs and symptoms of a stroke vary depend-
treatment for shock. Prevent any unnecessary ing on the part of the brain affected. Some
stress and avoid excessive movement because common signs and symptoms are numbness,
any activity places additional strain on the paralysis, eye pupils unequal in size, mental
heart. Reassure the victim constantly, and confusion, slurred speech, nausea, vomiting,
514 CHAPTER 16
difficulty breathing and swallowing, and loss allow the victim to get up gradually. If recovery
of consciousness. is not prompt, if other injuries occur or are
♦ First aid for a stroke victim is directed toward suspected, or if fainting occurs again, obtain
maintaining respirations, laying the victim medical help. Fainting can be a sign of a seri-
flat on the back with the head slightly elevated ous illness or condition that requires medical
or on the side to allow secretions to drain attention.
from the mouth, and avoiding any fluids by
mouth. Reassure the victim, prevent any
unnecessary stress, and avoid any unneces-
sary movement.
NOTE: Always remember that although the
CONVULSION
victim may be unable to speak or may A convulsion, which is a type of seizure, is a
appear to be unconscious, he or she may be strong, involuntary contraction of muscles. Con-
able to hear and understand what is going vulsions may occur in conjunction with high
on. body temperatures, head injuries, brain disease,
♦ Obtain medical help as quickly as possible. and brain disorders such as epilepsy.
Immediate care during the first 3 hours can ♦ Convulsions cause a rigidity of body muscles
help prevent brain damage. If the CVA is followed by jerking movements. During a con-
caused by a blood clot, treatment with throm- vulsion, a person may stop breathing, bite the
bolytic or “clot busting” drugs such as TPA tongue, lose bladder and bowel control, and
(tissue plasminogen activator) or angioplasty injure body parts. The face and lips may
of the cerebral arteries can dissolve a blood develop a cyanotic (bluish) color. The victim
clot and restore blood flow to the brain. may lose consciousness. After regaining con-
sciousness at the end of the convulsion, the
victim may be confused and disoriented, and
FAINTING complain of a headache.
Fainting occurs when there is a temporary ♦ First aid is directed toward preventing self-
reduction in the supply of blood to the brain. It injury. Removing dangerous objects from the
may result in partial or complete loss of con- area, providing a pillow or cushion under the
sciousness. The victim usually regains conscious- victim’s head, and providing artificial respira-
ness after being in a supine position (that is, lying tion, as necessary, are all ways to assist the
flat on the back). victim.
♦ Early signs of fainting include dizziness, ♦ Do not try to place anything between the vic-
extreme pallor, diaphoresis, coldness of the tim’s teeth. This can cause severe injury to
skin, nausea, and a numbness and tingling of your fingers, and/or damage to the victim’s
the hands and feet. teeth or gums.
♦ If early symptoms are noted, help the victim ♦ Do not use force to restrain or stop the muscle
to lie down or to sit in a chair and position his movements; this only causes the contractions
or her head at the level of the knees. to become more severe.
♦ If the victim loses consciousness, try to pre- ♦ When the convulsion is over, watch the victim
vent injury. Provide first aid by keeping the closely. If fluid, such as saliva or vomit, is in
victim in a supine position. If no neck or spine the victim’s mouth, position the victim on his
injuries are suspected, use a pillow or blankets or her side to allow the fluid to drain from the
to elevate the victim’s legs and feet 12 inches. mouth. Allow the victim to sleep or rest.
Loosen any tight clothing and maintain an ♦ Obtain medical help if the seizure lasts more
open airway. Use cool water to gently bathe than a few minutes, if the victim has repeated
the victim’s face. Check for any injuries that seizures, if other severe injuries are apparent,
may have been caused by the fall. Permit the if the victim does not have a history of sei-
victim to remain flat and quiet until color zures, or if the victim does not regain con-
improves and the victim has recovered. Then sciousness.
First Aid 515
tions that require first aid: diabetic coma and

DIABETIC REACTIONS insulin shock (figure 16-42).
Diabetes mellitus is a metabolic disorder caused ♦ Diabetic coma or hyperglycemia is caused by
by a lack or insufficient production of insulin (a an increase in the level of glucose in the blood-
hormone produced by the pancreas). Insulin stream. The condition may result from an
helps the body transport glucose, a form of sugar, excess intake of sugar, failure to take insulin, or
from the bloodstream into body cells where the insufficient production of insulin. Signs and
glucose is used to produce energy. When there is symptoms include confusion; weakness or
a lack of insulin, sugar builds up in the blood- dizziness; nausea and/or vomiting; rapid, deep
stream. Insulin injections can reduce and control respirations; dry, flushed skin; and a sweet or
the level of sugar in the blood. Individuals with fruity odor to the breath. The victim will even-
diabetes are in danger of developing two condi- tually lose consciousness and die unless the
Coma (Hyperglycemia) Shock (Hypoglycemia)

Appears in stupor Excited, nervous, dizzy,
or coma Headache confused, irritable,
behavior change,
Face flushed inappropriate responses
Face pale
Fruity odor
to breath
Tongue dry
Labored, prolonged Shallow or rapid

respirations respirations
Blood pressure low Normal blood pressure
Weak and rapid pulse Full and pounding pulse
Skin dry Skin moist —

excessive perspiration
Lack of coordination,
trembling
High Blood glucose Low
Positive for Urine Negative for

sugar and acetone sugar and acetone
FIGURE 16-42 Diabetic coma (hyperglycemia) versus insulin shock (hypoglycemia).
516 CHAPTER 16
condition is treated. Medical assistance must The intake of sugar should quickly control the
be obtained as quickly as possible. reaction. If the victim loses consciousness or
♦ Insulin shock or hypoglycemia is caused by convulsions start, provide care for the convul-
an excess amount of insulin (and a low level of sions and obtain medical assistance immedi-
glucose) in the bloodstream. It may result ately.
from failure to eat the recommended amounts, By observing symptoms carefully and obtain-
vomiting after taking insulin, or taking exces- ing as much information as possible from the vic-
sive amounts of insulin. Signs and symptoms tim, you can usually determine whether the
include muscle weakness; mental confusion; condition is diabetic coma or insulin shock. Ask
restlessness or anxiety; diaphoresis; pale, the victim, “Have you eaten today?” and “Have
moist skin; hunger pangs; and/or palpitations you taken your insulin?” If the victim has taken
(rapid, irregular heartbeats). The victim may insulin but has not eaten, insulin shock is devel-
lapse into a coma and develop convulsions. oping because there is too much insulin in the
The onset of insulin shock is sudden, and the body. If the victim has eaten but has not taken
victim’s condition can deteriorate quickly; insulin, diabetic coma is developing. In cases
therefore, immediate first aid care is required. when you know that the victim is diabetic but the
If the victim is conscious, give him or her a victim is unconscious and there are no definite
drink containing sugar, such as sweetened symptoms of either condition, you may not be
orange juice. A cube or teaspoon of granulated able to determine whether the condition is dia-
sugar can also be placed in the victim’s mouth. betic coma or insulin shock. In such cases, the
If the victim is confused, avoid giving hard recommendation is to put granulated sugar
candy. Unconsciousness could occur, and the under the victim’s tongue and activate emergency
victim could choke on the hard candy. Many medical services (EMS). This is the lesser of two
individuals with diabetes use tubes of glucose evils. If the patient is in diabetic coma, the blood-
that they carry with them (figure 16-43). If the sugar level can be lowered as needed when the
victim is conscious and can swallow and a victim is transported for medical care. If the vic-
glucose tube is available, it can be given to the tim is in insulin shock, however, brain damage
victim. can occur if the blood-sugar level is not raised
immediately. Medical care cannot correct brain
damage.
SUMMARY
In all cases of sudden illness, constantly
reassure the victim and make every attempt
to encourage the victim to relax and avoid further
stress. Be alert for the signs of shock and provide
treatment for shock to all victims. The pain, anxi-
ety, and fear associated with sudden illness can
contribute to shock.

FIGURE 16-43 A victim experiencing insulin the assignment sheet for 16:11, Providing First Aid
shock needs glucose or some form of sugar as for Sudden Illness. Then return and continue with
quickly as possible. the procedure.
First Aid 517
PROCEDURE 16:11
plete sitting position. If the victim is
Providing First Aid having difficulty breathing, use pil-
for Sudden Illness lows or rolled blankets to elevate the
head and shoulders.
Equipment and Supplies b. Obtain medical help for the victim
immediately. Advise EMS that oxy-
Blankets, pillows, sugar, clean cloth, cool
gen may be necessary.
water, disposable gloves
c. Encourage the victim to relax. Reas-
Procedure sure the victim. Remain calm and
encourage others to remain calm.
1. Follow the priorities of care, if indi- d. Watch for signs of shock and treat for
cated. shock as necessary. Avoid overheat-
a. Check the scene. Move the victim ing the victim.
only if absolutely necessary. e. If the victim complains of excessive
b. Check the victim for consciousness thirst, use a wet cloth to moisten the
and breathing. lips, tongue, and inside of the mouth.
Small sips of water can also be given
to the victim, but avoid giving large
(EMS), if necessary.
amounts of fluid.
CAUTION: Do not give the victim ice
e. Check for bleeding. Control severe water or very cold water because the
bleeding. cold can intensify shock.
CAUTION: If possible, wear gloves or 4. If you suspect that the victim has had a
use a protective barrier while control- stroke:
ling bleeding.
a. Place the victim in a comfortable
2. Closely observe the victim for specific position. Keep the victim lying flat or
signs and symptoms. If the victim is slightly elevate the victim’s head and
conscious, obtain information about shoulders to aid breathing. If the vic-
the history of the illness, type and tim has difficulty swallowing, turn
amount of pain, and other pertinent the victim on his or her side to allow
details. If the victim is unconscious, secretions to drain from the mouth
check for a medical bracelet or necklace and prevent choking on the secre-
or a medical information card. Always tions.
have a reason for everything you do.
b. Reassure the victim. Encourage the
Explain your actions to any observers,
victim to relax.
especially if it is necessary to check the
victim’s wallet for a medical card. c. Avoid giving the victim any fluids or
food by mouth. If the victim com-
3. If you suspect the victim is having a
plains of excessive thirst, use a cool,
heart attack, provide first aid as follows:
wet cloth to moisten the lips, tongue,
a. Place the victim in the most comfort- and inside of the mouth.
able position possible, but avoid
d. Obtain medical help for the victim as
unnecessary movement. Some vic-
quickly as possible.
tims will want to lie flat, but others
will want to be in a partial or com-
518 CHAPTER 16
PROCEDURE 16:11
5. If the victim has fainted: NOTE: If breathing does not resume
quickly, artificial respiration may be
a. Keep the victim in a supine position
necessary.
(that is, lying flat on the back). Raise
the legs and feet 12 inches. d. Do not try to place anything between
the victim’s teeth. This can cause
b. Check for breathing. Provide artifi-
injury to the teeth and/or gums.
cial respiration, if necessary.
e. Do not attempt to restrain the muscle
c. Loosen any tight clothing.
contractions. This only makes the
d. Use cool water to gently bathe the contractions more severe.
face.
f. Note how long the convulsion lasts
e. Check for any other injuries. and what parts of the body are
f. Encourage the victim to continue involved. Be sure to report this infor-
lying down until his or her skin color mation to the EMS personnel.
improves. g. After the convulsion ends, closely
g. If no other injuries are suspected, watch the victim. Encourage the vic-
allow the victim to get up slowly. First, tim to rest.
elevate the head and shoulders. Then h. Obtain medical assistance if the con-
place the victim in a sitting position. vulsion lasts more than a few min-
Allow the victim to stand slowly. If utes, if the victim has repeated
any signs of dizziness, weakness, or convulsions, if other severe injuries
pallor are noted, return the victim to are apparent, if the victim does not
the supine position. have a history of convulsions, or if
h. If the victim does not recover quickly, the victim does not regain conscious-
or if any other injuries occur, obtain ness.
medical care. If fainting has occurred 7. If the victim is in diabetic coma:
frequently, refer the victim for medi-
a. Place the victim in a comfortable
cal care.
position. If the victim is unconscious,
NOTE: Fainting can be a sign of a seri- position him or her on either side to
ous illness or condition. allow secretions to drain from the
6. If the victim is having a convulsion: mouth.
a. Remove any dangerous objects from b. Frequently check respirations. Pro-

the area. If the victim is near heavy vide artificial respiration as needed.
furniture or machinery that cannot c. Obtain medical help immediately so
be moved, move the victim to a safe the victim can be transported to a
area. medical facility.
b. Place soft material such as a blanket, 8. If the victim is in insulin shock:
small pillow, rolled jacket, or other
a. If the victim is conscious and can
similar material under the victim’s
swallow, offer a drink containing
head to prevent injury.
sugar or oral glucose if a tube is avail-
c. Closely observe respirations at all able.
times. During the convulsion, there
b. If the victim is unconscious, place a
will be short periods of apnea (cessa-
small amount of granulated sugar
tion of breathing).
under the victim’s tongue.
First Aid 519
PROCEDURE 16:11
c. Place the victim in a comfortable
position. Position an unconscious
victim on either side to allow secre-
tions to drain from the mouth. Practice
d. If recovery is not prompt, obtain evaluation sheet for 16:11,
medical help immediately. Providing First Aid for Sudden
9. Observe all victims of sudden illness for Illness, to practice this procedure.
signs of shock. Treat for shock as neces- When you believe you have
sary. mastered this skill, sign the sheet
10. Constantly reassure any victim of sud- and give it to your instructor for
den illness. Encourage relaxation to further action.
decrease stress.
11. Wash hands thoroughly after providing Final Checkpoint Using the criteria
care. listed on the evaluation sheet, your
16:12 INFORMATION
Applying Dressings
and Bandages
In many cases requiring first aid, it will be neces-
sary for you to apply dressings and bandages.
This section provides basic information on types
of bandages and dressings and on application
methods.
A dressing is a sterile covering placed over a
wound or an injured part. It is used to control
bleeding, absorb blood and secretions, prevent FIGURE 16-44 Dressings to cover a wound are
infection, and ease pain. Materials that may be available in many different sizes.
used as dressings include gauze pads in a variety
of sizes and compresses of thick, absorbent mate- ♦ Roller gauze bandages come in a variety of
rial (figure 16-44). Fluff cotton should not be used widths, most commonly 1-, 2-, and 3-inch
as a dressing because the loose cotton fibers may widths. They can be used to hold dressings in
contaminate the wound. In an emergency when place on almost any part of the body.
no dressings are available, a clean handkerchief
or pillowcase may be used. The dressing is held in ♦ Triangular bandages can be used to secure
place with tape or a bandage. dressings on the head/scalp or as slings. A tri-
Bandages are materials used to hold dress- angular bandage is sometimes used as a cov-
ings in place, to secure splints, and to support and ering for a large body part such as a hand,
protect body parts. Bandages should be applied foot, or shoulder. By folding the triangular
snugly enough to control bleeding and prevent bandage into a band of cloth called a cravat
movement of the dressing, but not so tightly that (figure 16-46), the bandage can be used to
they interfere with circulation. Types of bandages secure splints or dressings on body parts.
include roller gauze bandages, triangular ban- ♦ Elastic bandages are easy to apply because
dages, and elastic bandages (figure 16-45). they readily conform, or mold, to the injured
520 CHAPTER 16
part. However, they can be quite hazardous; if

they are applied too tightly or are stretched
during application, they can cut off or con-
strict circulation. Elastic bandages are some-
times used to provide support and stimulate
circulation.
Several methods are used to wrap bandages.
The method used depends on the body part
involved. Some common wraps include the spiral
wrap, the figure-eight wrap for joints, and the fin-
ger, or recurrent, wrap. The wraps are described
in Procedure 16:12, immediately following this
FIGURE 16-45 Roller gauze and elastic ban- information section.
dages can be used to hold dressings in place. After any bandage has been applied, it is
important to check the body part below the ban-
dage to make sure the bandage is not so tight as
to interfere with blood circulation. Signs that
indicate poor circulation include swelling, a pale
or blue (cyanotic) color to the skin, coldness to
the touch, and numbness or tingling. If the ban-
dage has been applied to the hand, arm, leg, or
foot, press lightly on the nail beds to blanch them
(that is, make them turn white). The pink color
should return to the nail beds immediately after
pressure is released. If the pink color does not
return or returns slowly, this is an indication of
poor or impaired circulation. If any signs of
impaired circulation are noted, loosen the ban-
dages immediately.

the assignment sheet for 16:12, Applying Dressings
FIGURE 16-46 Folding a cravat bandage from a and Bandages. Then return and continue with the
triangular bandage. procedure.
PROCEDURE 16:12
2. Wash hands. Put on gloves if there is any
Applying Dressings chance of contact with blood or body
and Bandages fluids.
3. Apply a dressing to a wound as follows:
Equipment and Supplies a. Obtain the correct size dressing. The
Sterile gauze pads, triangular bandage, roller dressing should be large enough to
gauze bandage, elastic bandage, tape, dispos- extend at least 1 inch beyond the
able gloves edges of the wound.
b. Open the sterile dressing package,
Procedure taking care not to touch or handle
the sterile dressing with your fingers.
First Aid 521
PROCEDURE 16:12
c. Use a pinching action to pick up the Point
sterile dressing so you handle only
one part of the outside of the dress-
ing. The ideal situation would involve Base A
the use of sterile transfer forceps or End
sterile gloves to handle the dressing.
However, these items are usually not
available in emergency situations. B C
d. Place the dressing on the wound. The

untouched (sterile) side of the dress-
ing should be placed on the wound.
Do not slide the dressing into posi-
tion. Instead, hold the dressing
directly over the wound and then
lower the dressing onto the wound.
D E
e. Secure the dressing in place with tape
or with one of the bandage wraps.
CAUTION: If tape is used, do not wrap it
completely around the part. This can
lead to impaired circulation.
4. Apply a triangular bandage to the head
or scalp (figure 16-47):
a. Fold a 2-inch hem on the base (lon- F G
gest side) of the triangular bandage. FIGURE 16-47 Steps for applying a triangular
bandage to the head or scalp.
b. Position and secure a sterile dressing
in place over the wound.
the bandage is snug against the
c. Keeping the hem on the outside, head.
position the middle of the base of the
h. Bring the point up and tuck it into
bandage on the forehead, just above
the bandage where the bandage
the eyebrows.
crosses at the back of the head.
d. Bring the point of the bandage down
5. Make a cravat bandage from a triangu-
over the back of the head.
lar bandage (review figure 16-46):
e. Bring the two ends of the base of the
a. Bring the point of the triangular ban-
bandage around the head and above
dage down to the middle of the base
the ears. Cross the ends when they
(the long end of the bandage).
meet at the back of the head. Bring
them around to the forehead. b. Continue folding the bandage length-
wise until the desired width is
f. Use a square knot to tie the ends in
obtained.
the center of the forehead.
6. Apply a circular bandage with the cravat
g. Use one hand to support the head.
bandage (figure 16-48):
Use the other hand to gently but
firmly pull down on the point of the a. Place a sterile dressing on the
bandage at the back of the head until wound.
522 CHAPTER 16
PROCEDURE 16:12
b. Place the center of the cravat ban-
dage over the sterile dressing.
c. Bring the ends of the cravat around
the body part and cross them when
they meet.
d. Bring the ends back to the starting
point.
e. Use a square knot to tie the ends of
the cravat over the dressing.
CAUTION: Avoid tying or wrapping the
bandage too tightly. This could impair
circulation.
NOTE: Roller gauze bandage can also be
used.
CAUTION: This type of wrap is never
used around the neck because it could
strangle the victim.
7. Apply a spiral wrap using roller gauze
bandage or elastic bandage:
a. Place a sterile dressing over the
wound.
b. Hold the roller gauze or elastic ban-
dage so that the loose end is hanging
off the bottom of the roll.
c. Start at the farthest end (the bottom
of the limb) and move in an upward
direction.
d. Anchor the bandage by placing it on
an angle at the starting point. To do
this, encircle the limb once, leaving a
corner of the bandage uncovered.
Turn down this free corner and then
encircle the part again with the ban-
dage (figure 16-49A).
e. Continue encircling the limb. Use a
FIGURE 16-48 Steps for applying a circular spiral type motion to move up the
bandage with a cravat bandage.
limb. Overlap each new turn approxi-
mately half the width of the ban-
dage.
f. Use one or two circular turns to fin-
ish the wrap at the end point.
First Aid 523
PROCEDURE 16:12
FIGURE 16-49B Place your hand between

the bandage and the victim’s skin while insert-
ing a pin.
c. Make one or two circular turns

around the instep and foot (figure
16-50A).
d. Bring the bandage up over the foot
in a diagonal direction. Bring it
around the back of the ankle and
then down over the top of the foot.
Circle it under the instep. This cre-
ates the figure-eight pattern.
FIGURE 16-49A Anchor the bandage by
leaving a corner exposed. This corner is then e. Repeat the figure-eight pattern. With
folded down and covered when the bandage is each successive turn, move down-
circled around the limb. ward and backward toward the heel
g. Secure the end by taping, pinning, or

tying. To avoid injury when pins are
used, place your hand under the
double layer of bandage and between
the pin and the skin before inserting
the pin (figure 16-49B). The end
of the bandage can also be cut in half
and the two halves brought around
opposite sides and tied into place.
8. Use roller gauze bandage or elastic ban-
dage to apply a figure-eight ankle wrap:
a. Position a dressing over the wound.
FIGURE 16-50A Bring the bandage over the
b. Anchor the bandage at the instep of foot in a diagonal direction for the start of the
the foot. figure-eight pattern.
524 CHAPTER 16
PROCEDURE 16:12
(figure 16-50B). Overlap the previous
turn by one-half to two-thirds the
width of the bandage.
NOTE: Hold the bandage firmly but do
not pull it too tightly. If you are using
elastic bandage, avoid stretching the
material during the application.
f. Near completion, use one or two final
circular wraps to circle the ankle.
g. Secure the bandage in place by tap-
ing, pinning, or tying the ends, as
described in step 7g.
CAUTION: To avoid injury to the victim
when pins are used, place your hand
between the bandage and the victim’s
skin.
9. Use roller gauze bandage to apply a
recurrent wrap to the fingers (figure
16-51).
a. Place a sterile dressing over the
wound.
b. Hold the roller gauze bandage so that
the loose end is hanging off the bot-
tom of the roll.
c. Place the end of the bandage on the
bottom of the finger. Then bring the
bandage up to the tip of the finger
and down to the bottom of the oppo-
FIGURE 16-51 Recurrent wrap for the finger
FIGURE 16-50B Keep repeating the figure-

eight pattern by moving downward and back-
ward toward the heel with each turn.
First Aid 525
PROCEDURE 16:12
site side of the finger. With overlap- including swelling, coldness, numbness
ping wraps, fold the bandage or tingling, pallor or cyanosis, and poor
backward and forward over the finger return of pink color after nail beds are
three or four times. blanched by lightly pressing on them. If
any signs of poor circulation are noted,
d. Start at the bottom of the finger and
loosen the bandages immediately.
use a spiral wrap up and down the
finger to hold the recurrent wraps in 11. Obtain medical help for any victim who
position. may need additional care.
e. Complete the bandage by using a fig- 12. Remove gloves and wash hands.
ure-eight wrap around the wrist.
Bring the bandage in a diagonal
direction across the back of the hand.
Circle the wrist at least two times.
Bring the bandage back over the top Practice
of the hand and circle the bandaged Go to the workbook and use the
finger. Repeat this figure-eight evaluation sheet for 16:12, Applying
motion at least twice. Dressings and Bandages, to practice
f. Secure the bandage by circling the
wrist once or twice. Tie the bandage
at the wrist.
10. After any bandage has been applied,
check the circulation below the bandage
at frequent intervals. If possible, check Final Checkpoint Using the criteria
for a pulse at a site below the bandage. listed on the evaluation sheet, your
Note any signs of impaired circulation, instructor will grade your performance.
The basic principles of first aid were pre-

CHAPTER 16 SUMMARY sented in this unit. Methods of cardiopulmonary
resuscitation (CPR) for infants, children, adults,
and choking victims were described. Proper first
First aid is defined as “the immediate care given aid for bleeding, shock, poisoning, burns, heat
to the victim of an injury or illness to minimize and cold exposure, bone and joint injuries, spe-
the effect of the injury or illness until experts can cific injuries, and sudden illness were covered.
take over.” Nearly everyone at some time experi- Instructions were given for the application of
ences situations for which a proper knowledge common dressings and bandages. By learning
of first aid is essential. It is important to follow and following the suggested methods, the health
correct techniques while administering first aid care worker can provide correct first aid treat-
and to provide only the treatment you are quali- ment in emergency situations until the help of
fied to provide. experts can be obtained.
526 CHAPTER 16

A microchip to cure diabetes?
Diabetes mellitus is a chronic disease caused by a decreased secretion of insulin, a hor-
mone that is needed by body cells to absorb glucose (sugar) from the blood. In the United
States, approximately 18.2 million people, or 6.3 percent of the population, have diabetes.
Many of these individuals have insulin-dependent diabetes, which means they must inject
daily doses of insulin to maintain blood glucose levels. For years, researchers have been
looking for a technology that will end the need for individuals with diabetes to use needles
to inject insulin and to constantly prick the skin to draw blood for glucose monitoring.
One researcher, Tejal Desai, has been successful in curing rats with diabetes by using a
biological microelectromechanical system (MEMS), commonly called bioMEMS. BioMEMS
are tiny devices that use microchips. Desai built a small implantable capsule with tiny pores,
smaller than 1/100 of a human hair, on the surface. She placed live insulin-secreting pancre-
atic cells inside the capsule. The tiny pores on the capsule allow nutrients, waste products,
and insulin to pass through, but are so small they prohibit harmful antibodies from entering
the capsule. Because the body does not like foreign objects in the bloodstream, it produces
antibodies to kill the objects. By blocking the antibodies, Desai appears to have eliminated
the problem of rejection, allowing the implanted device to remain in the body where it can
monitor the blood glucose level and secrete insulin as needed.
It will be several more years before Desai’s research will be used on humans, but many
scientists are currently using her ideas to create bioMEMS that can be used to cure disease.
Some researchers are evaluating capsules that secrete blood-clotting factors for individuals
with hemophilia. Others are trying to develop capsules that will carry dopamine to treat
Parkinson’s disease. Think of a future in which tiny capsules floating in the bloodstream or
implanted in the body cure chronic diseases and allow individuals to live long and healthy
lives.
INTERNET SEARCHES hypothermia, frostbite, fractures, dislocations,

sprains, strains, eye injuries, nose injuries,
Use the suggested search engines in Chapter 12:4 head and skull injuries, spine injuries, chest
of this textbook to search the Internet for addi- injuries, abdominal injuries, myocardial
tional information on the following topics: infarction, cerebrovascular accident, fainting,
convulsions or seizures, diabetic coma, and
1. Organizations: find Web sites for the American
insulin shock
Red Cross, the American Heart Association,
Emergency Medical Services, and Poison
Control Centers to learn services offered
REVIEW QUESTIONS
2. CPR: look for sites that discuss the principles of
cardiopulmonary resuscitation, abdominal Review the following case histories. List the cor-
thrusts, and cardiac emergencies rect first aid care, in proper order of use, that
should be used to treat each victim.
3. Automated external defibrillators: search for
manufacturers of AEDs and compare different 1. You are slicing carrots and cut off the end of
models your finger.
4. First aid treatments: find information on 2. You find your 2-year-old brother in the bath-
recommended treatment for bleeding, room. An empty bottle of aspirin tablets is on
wounds, shock, poisoning, snakebites, insect the floor. His mouth is covered with a white
stings, ticks, burns, heat exposure, heat stroke, powdery residue.
First Aid 527
3. You are watching television with your parents. For additional information on first aid and emer-
Suddenly your father complains of severe pain gency care, write to:
in his chest and left arm. He is very short of
♦ American Red Cross—contact your local chap-
breath and his lips appear cyanotic.
ter for First Aid and CPR courses and certifica-
4. You are working in chemistry lab. Suddenly an tion, or check the Web site at: www.redcross.
experiment boils over and concentrated org
hydrochloric acid splashes into your lab ♦ American Heart Association—contact your
partner’s face and eyes. She starts screaming local chapter for CPR courses and certification
with pain. or check the Web site at: www.americanheart.
5. You are driving and the car ahead of you loses org
control, goes off the road, and hits a tree. When ♦ Contact the National Highway Traffic Safety
you get to the car, the driver is slumped over Administration (NHTSA), U.S. Department of
the wheel. His arm is twisted at an odd angle. Transportation, Emergency Medical Services
You notice a small fire at the rear of the car. A Branch N-42-13, Washington, D.C. 20540 or
small child is crying in a car seat in the back check the Web at: www.nhtsa.dot.gov (click
seat. link to traffic safety and then emergency med-
6. You are playing tennis on a hot summer day ical services)
with a friend. Suddenly your friend collapses
on the tennis court. When you get to her, her
skin is hot, red, and dry. She is breathing but
she is unconscious.
CHAPTER 17 Preparing for the
World of Work
Chapter Objectives
Observe Standard
Precautions
◆ Identify at least five job-keeping skills and
explain why employers consider them to be
essential skills
◆ Write a cover letter containing all required
information and using correct form for letters
◆ Prepare a résumé containing all necessary
Caution
information and meeting standards for
neatness and correctness
◆ Complete a job application form that meets
on Federal Law
standards of neatness and accuracy
◆ Demonstrate how to participate in a job
interview, including wearing correct dress and
Math Skill
meeting standards established in this chapter
◆ Determine gross and net income
◆ Calculate an accurate budget for a one-month
period, accounting for fixed expenses and
Science Skill variable expenses without exceeding net
monthly income
Technology
Preparing for the World of Work 529
KEY TERMS
application forms fixed expenses letter of application
budget gross income net income
cover letter income résumé (rezⴕ-ah-may)
deductions job interview variable expenses
standard English books or secretarial manuals

17:1 INFORMATION for information on sentence structure and
punctuation. Constantly strive to improve
Developing Job-Keeping Skills both oral and written communication skills.
To obtain and keep a job you must develop cer- ♦ Report to work on time and when scheduled.
tain characteristics to be a good employee. A Because many health care facilities provide
recent survey of employers asked for information care 7 days a week, 365 days per year, and
on the deficiencies of high school graduates. The often 24 hours per day, an employee who is
most frequent complaints included poor written frequently late or absent can cause a major
grammar, spelling, speech, and math skills. Other disruption in schedule and contribute to an
complaints included lack of respect for work, lack insufficiency of personnel to provide patient
of self-initiative, poor personal appearance, not care. Most health care facilities have strict
accepting responsibility, excessive tardiness, rules regarding absenteeism, and a series of
poor attendance, and inability to accept criti- absences can result in job loss.
cism. Any of these defects would be detrimental
in a health care worker. ♦ Be prepared to work when you arrive at work.
It is essential that you develop good job-keep- An employer does not pay workers to social-
ing skills to be successful in a health care career. ize, make personal telephone calls, consult
Being aware of and striving to achieve the quali- others about personal or family problems,
ties needed for employment are as important as bring their children to work, shop on the Inter-
acquiring the knowledge and skills required in net, play games on a computer, or work in a
your chosen health care profession. sloppy and inefficient manner. Develop a good
Job-keeping skills include: work ethic. Observe all legal and ethical
responsibilities. Follow the policies and pro-
♦ Use correct grammar at all times. This cedures of your health care facility. Recognize
includes both the written and spoken your limitations and seek help when you need
word. Patients often judge ability on how well it. Be willing to learn new procedures and
a person speaks or writes information. Use of techniques. Watch efficient and knowledge-
words like ain’t indicates a lack of education able staff members and learn by their exam-
and does not create a favorable or profes- ples. Constantly strive to do the best job
sional impression. You must constantly strive possible. A worker who has self-initiative, who
to use correct grammar. Listen to how other sees a job that needs to be done and does it, is
health care professionals speak and review a valuable employee who is likely to be recog-
basic concepts of correct grammar. It may nized and rewarded.
even be necessary to take a communications ♦ Practice teamwork. Because health care typi-
course to learn to speak correctly. Because you cally involves a team of different professionals
will be completing legal written records for working together to provide patient care, it is
health care, the use of correct spelling, punc- important to be willing to work with others. If
tuation, and sentence structure is also essen- you are willing to help others when they need
tial. Use a dictionary to check spelling, or use help, they will likely be willing to help you.
the spell check on a computer system. Refer to Two or three people working together can lift
530 CHAPTER 17
a heavy patient much more readily than can

one.
♦ Promote a positive attitude. By being positive,
you create a good impression and encourage
the same attitude in others. Too often, employ-
ees concentrate only on the negative aspects
of their jobs. Every job has some bad points;
and it is easy to criticize these points. It is also
easy to criticize the bad points in others with
whom you work. However, this leads to a neg-
ative attitude and helps create poor morale in
everyone. By concentrating on the good
aspects of a job and the rewards it can provide,
work will seem much more pleasant, and
employees will obtain more satisfaction from
their efforts. FIGURE 17-1 Participating in staff development
programs is one way to improve your own knowl-
♦ Accept responsibility for your actions. Most edge and skills.
individuals are more than willing to take credit
for the good things they have done. In the
same manner, it is essential to take responsi-
bility for mistakes. If you make a mistake,
report it to your supervisor and make every to be the best you can be. If you do this, you will
effort to correct the error. Every human being not only be likely to retain your job, but you will
will do something wrong at some time. Recog- probably be rewarded with job advancement,
nizing an error, taking responsibility for it, and increased salary, and personal satisfaction.
making every effort to correct it or prevent it
from happening again is a sign of a competent STUDENT: Go to the workbook and complete
worker. Honesty is essential in health care. the assignment sheet for 17:1, Developing Job-
Not accepting responsibility for your actions Keeping Skills.
is dishonest. It is often a reason for dismissal
and can prevent you from obtaining another
position.
17:2 INFORMATION
♦ Be willing to learn. Health care changes con- Writing a Cover Letter
stantly because of advances in technology and and Preparing a Résumé
research. Every health care worker must be
willing to learn new things and adapt to INTRODUCTION
change. Participating in staff development
programs (figure 17-1), taking courses at tech- Before you look for a job, evaluate your interests
nical schools or colleges, attending special and abilities. Decide what type job you would
seminars or meetings, reading professional like. Make sure you obtain the education needed
journals, and asking questions of other quali- to perform the job. Then look at different job
fied individuals are all ways to improve your sources to try to find a position you will like. There
knowledge and skills. Employers recognize are many different sources for finding job open-
these efforts. Ambition is often rewarded with ings. Some of them include:
a higher salary and/or job advancement. ♦ Advertisements in newspapers
Without good job-keeping skills, no amount ♦ Job fairs sponsored by schools or employment
of knowledge will help you keep a job. Therefore, agencies
it is essential for you to strive to develop the ♦ Recommendations from friends and relatives
qualities that employers need in workers. Be
courteous, responsible, enthusiastic, coopera- ♦ School counselors or bulletin boards
tive, reliable, punctual, and efficient. Strive hard ♦ Employment agencies
♦ Internet job search sites ♦ Paragraph two: state why you believe you are
♦ Professional organizations: check their Inter- qualified for the position. It may also state
net site or contact the local organization why you want to work for this particular
employer. Information should be brief because
♦ Job listings posted at health care facilities or most of the information will be included on
listed on their Internet site your résumé.
Once you have identified possible places of ♦ Paragraph three: state that a résumé is
employment, prepare to apply for the position. In included. You may also want to draw the
most cases, this involves writing a cover letter, or employer’s attention to one or two important
letter of application, and a résumé. features on your résumé. If you are not includ-
ing a résumé, state that one is available on
request. Whenever possible, it is best to enclose
COVER LETTER a résumé.
♦ Paragraph four: closes the letter with a request
The purpose of a cover letter or letter of appli- for an interview. Be sure you clearly state how
cation is to obtain an interview. You must create the employer can contact you for additional
a good impression in the letter so that the information. Include a telephone number and
employer will be interested in hiring you. In many the times you will be available to respond to a
cases, you will be responding to a job advertised telephone call. Finally, include a thank you to
either in the newspaper, on the Internet, or the potential employer for considering your
through other sources. However a résumé may be application.
sent to potential employers even though they
have not advertised a job opportunity. A cover Figure 17-2 is a sample cover letter to serve as
letter should accompany all résumés. a guide to writing a good letter. However, remem-
The letter should be computer printed or ber this is only one guide. Letters must be varied
typewritten on good quality paper. It must be to suit each circumstance.
neat, complete, and done according to correct
form for letters. The correct form for composing
business letters is discussed in detail in Chapter RÉSUMÉ
23:5 of this textbook. Care must be taken to ensure
A résumé is a record of information about an
that spelling and punctuation are correct.
individual. It is a thorough yet concise summary
Remember, this letter is the employer’s first
of an individual’s education, skills, accomplish-
impression of you.
ments, and work experience. It is used to provide
If possible, the letter should be addressed to
an employer with basic information that makes
the correct individual. If you know the name
you appear qualified as an employee. At the same
of the agency or company, call to obtain this
time, a good résumé will help you clarify your job
information. Be sure you obtain the correct spell-
objective and be better prepared for a job inter-
ing of the person’s name as well as the person’s
view.
correct title. If you are responding to a box num-
A résumé should be computer printed or
ber, follow the instructions in the advertisement.
typed and attractive in appearance. Like a cover
Another possibility is to address the letter to the
letter, a résumé creates an impression on the
director of human resources or the head of a par-
employer. Information should be presented in an
ticular department.
organized fashion. At the same time, the résumé
The letter usually contains three to four para-
should be concise and pertinent. Good-quality
graphs. The contents of each paragraph are
paper; correct spelling and punctuation; straight,
described as follows:
even margins; and an attractive style are essen-
♦ Paragraph one: state your purpose for writing tial. If an individual is sending out a series of
and express interest in the position for which résumés, professional copies are permitted. How-
you are applying. If you are responding to an ever, the copies must be clear, on good-quality
advertisement, state the name and date of the paper, and appealing in appearance.
publication. If you were referred by another Résumé format can vary. Review sample
individual, give this person’s name and title. sources and find a style that you feel best pre-
532 CHAPTER 17
18 Hireme Lane
Job City, Ohio 44444
June 3, 20--
Mr. Prospective Employer

Director of Human Resources
Health Care Facility
12 Nursing Lane
Dental City, Ohio 44833
Dear Mr. Employer:
In response to your advertisement in the ___________________

on ___________________, 20 ______, I would like to apply for
the position of ____________________.
I recently graduated from ____________________. I majored in

___________________ and feel I am well qualified for this
position. I enjoy working with people and have a sincere
interest in additional training in ___________________.
My resume is enclosed. I have also enclosed a specific list of

skills that I mastered during my school experience. I feel
that previous positions noted on the resume have provided me
with a good basis for meeting your job requirements.
Thank you for considering my application. I would appreciate

a personal interview at your earliest convenience to discuss
my qualifications. Please contact me at the above address or
by telephone at 589-1111 after 2:00 PM any day.
Sincerely,
Iamjob Hunting
FIGURE 17-2 A sample cover letter.
sents your information. A one-page résumé is ♦ Personal identification: This includes your
usually sufficient. name, address, and telephone number. Be
Parts of a résumé can also vary. Some of the sure to include the area code.
most important parts that should be included are
shown in figures 17-3A and 17-3B and are
♦ Employment objective, job desired, or career
goal: Briefly state the title of the position for
described as follows:
which you are applying.
FIGURE 17-3A A sample résumé with information centered.

534 CHAPTER 17
THOMAS J. TOOTH
340 DENTAL LANE FLOSS, OHIO 44598 (524) 333-2435
CAREER GOAL: POSITION AS A DENTAL ASSISTANT IN GENERAL PRACTICE WITH A

GOAL OF BECOMING A CERTIFIED DENTAL ASSISTANT
EDUCATION: OHIO JOINT VOCATIONAL SCHOOL, OPPORTUNITY, OHIO 44597

GRADUATED IN JUNE 2007
MAJORED IN DENTAL ASSISTANT PROGRAM FOR TWO YEARS
SKILLS: IDENTIFICATION OF TEETH, CHARTING CONDITIONS OF THE

TEETH, MIXING DENTAL CEMENTS AND BASES, POURING MODELS
AND CUSTOM TRAYS, PREPARING ANESTHETIC SYRINGE, SETTING
UP BASIC DENTAL TRAYS, STERILIZING OF INSTRUMENTS,
DEVELOPING AND MOUNTING RADIOGRAPHS, TYPING BUSINESS LETTERS,
COMPLETING INSURANCE FORMS
WORK DENTAL LAB PRODUCTS, 55 MODEL STREET, FLOSS, OHIO 44598

EXPERIENCE: EMPLOYED SEPTEMBER 2006 TO PRESENT AS DENTAL LAB ASSISTANT
PROFICIENT IN MODELS, CUSTOM TRAYS, PROSTHETIC DEVICES
DRUGGIST STORES, 890 PHARMACY LANE, OPPORTUNITY, OHIO 44597

EMPLOYED JUNE 2004 TO AUGUST 2006 AS SALESPERSON
EXPERIENCE IN CUSTOMER RELATIONS, INVENTORY, REGISTER, AND
SALES PROMOTION
ACTIVITIES: HEALTH OCCUPATIONS STUDENTS OF AMERICA (HOSA) TREASURER

FIRST PLACE STATE AWARD IN HOSA DENTAL ASSISTANT CONTEST
VOLUNTEER WORKER DURING DENTAL HEALTH WEEK
MEMBER OF SCHOOL PEP CLUB
HOBBIES INCLUDE FOOTBALL, SWIMMING, BASKETBALL, READING
VOLUNTEER FOR MEALS-ON-WHEELS
PERSONAL DEPENDABLE, CONSIDERATE OF OTHERS, WILLING TO LEARN,

TRAITS: ADAPTABLE TO NEW SITUATIONS, RESPECTFUL AND HONEST,
ADEPT AT DENTAL TERMINOLOGY, ABLE TO PERFORM A VARIETY
OF DENTAL SKILLS
FIGURE 17-3B A sample résumé with left margin highlights.
♦ Educational background: List the name and school, this information should be placed
address of your high school. Be sure to include first.
special courses or majors if they relate to the ♦ Work or employment experience: This includes
job position. If you have taken additional previous positions of employment. Always
courses or special training, list them also. If start with the most recent position and work
you have completed college or technical backward. Each entry should include the
name and address of the employer, dates false information can cost you a job. If you have
employed, your job title, and a brief descrip- an A to B average in school, include this informa-
tion of duties. Avoid use of the word I. For tion. If your average is lower than an A to B, do
example, instead of stating, “I sterilized sup- not include this information.
plies,” state, “sterilized supplies,” using action Before preparing your résumé, it is important
verbs to describe duties. to list all of the information you wish to include.
Then select the format that best presents this
♦ Skills: List special knowledge, computer, and
information. The two sample résumés shown in
work skills you have that can be used in the
figures 17-3A and 17-3B are meant to serve as
job you are seeking. The list of skills should be
guidelines only. Do not hesitate to evaluate other
specific and indicate your qualifications and
formats and present your information in the best
ability to perform the job duties. When work
possible way.
experience is limited, a list of skills is impor-
The envelope should be the correct size for
tant to show an employer that you are quali-
your letter of application and résumé. Do not fold
fied for the position.
the letter into small sections and put it in an
♦ Other activities: These can include organiza- undersized envelope. This creates a sloppy
tions of which you are a member, offices held, impression. When possible, it is best to buy stan-
community activities, special awards received, dard business envelopes that match your paper.
volunteer work, hobbies, special interests, and A 9 12 envelope eliminates the need to fold the
other similar facts. Keep this information brief, cover letter and résumé, and helps create a more
but do not hesitate to include facts that indi- professional appearance. Be sure the envelope is
cate school, church, and community involve- addressed correctly and neatly. It should also be
ment. This section can show an employer that computer printed or typewritten.
you are a well-rounded person who partici-
pates in activities, assumes leadership roles,
strives to achieve, and practices good citizen-
ship. Write out the full names of organizations CAREER PASSPORT
rather than the identifying letters. OR PORTFOLIO
♦ References: Most sources recommend not A career passport or portfolio is a professional way
including references on a resume. Even the
to highlight your knowledge, abilities, and skills
statement “references will be furnished on
as you prepare for employment or extended edu-
request” is now usually omitted. However, at
cation. It allows you to present yourself in an
least three references should be placed on a
organized and efficient manner when you inter-
separate sheet of paper. The paper should be
view for schools or employment. Most career
the same paper used for the résumé and
passports or portfolios contain the following
include the same heading showing your name,
types of information:
address, and telephone number. The reference
sheet can be given to an employer during the ♦ Introductory letter: provides a brief synopsis of
job interview. For a high school student with yourself including your background, educa-
limited experience, references can provide tion, and future goals
valuable additional information. Always be ♦ Résumé: provides an organized record of infor-
sure you have an individual’s permission before mation on education, employment experi-
using that person as a reference. List the full ence, special skills, and activities
name, title, address, and telephone number of
the reference. It is best not to use relatives or
♦ Skill list and competency level: provides a list
of skills you have mastered and the level of
high school friends as references. Select pro-
competency for each skill; some health occu-
fessionals in your field, clergy, teachers, or
pation programs provide summaries of com-
other individuals with responsible positions.
petency evaluations that can be used; if your
Honesty is always the best policy, and this is program does not provide this, a list of skills
particularly true regarding résumés. Never give and final competency grades can be compiled
information that you think will look good but is by using the evaluation sheets in the Diversi-
exaggerated or only partly true. Inaccurate or fied Health Occupations Workbook
536 CHAPTER 17
♦ Letter(s) of recommendation: include letters of from diverse backgrounds), utilize informa-

recommendation from your instructors, guid- tion (acquire and evaluate data, file informa-
ance counselors, supervisors at clinical areas tion, interpret information, and communicate
or agencies where you perform volunteer with others), comprehend systems (understand
work, respected members of the community, social, organizational, and technical systems),
advisors of activities in which you participate, and use technologies (use computers, apply
and presidents of organizations of which you technology to specific tasks, and maintain
are a member equipment). Write brief paragraphs to docu-
ment how you have mastered skills such as
♦ Copies of work evaluations: include copies of
teamwork, self-motivation, leadership, a will-
evaluations you receive at job-training sites,
ingness to learn, responsibility, organization,
volunteer activities, and/or paid work experi-
and other SCANS qualities
ences
♦ Leadership and organization abilities: include
♦ Documentation of mastering job-keeping information that demonstrates leadership and
skills: the federal government has created
organization abilities you have mastered; par-
SCANS, or the Secretaries Commission on
ticipation in HOSA or Skills USA should be
Acquiring Necessary Skills, to designate skills
included
employers desire in employees. SCANS lists
three foundation skills that employers desire: Organize the above information in a neat
basic skills (able to read, write, solve math binder or portfolio. Use tab dividers to separate it
problems, speak, and listen), thinking skills into organized sections. Make sure that you use
(able to learn, reason, think creatively, make correct grammar and punctuation on all written
decisions, and solve problems), and personal information. The effort you put into creating a
qualities (display responsibility, self-initiative, professional portfolio or passport will be benefi-
sociability, honesty, and integrity). In addi- cial when you have this document ready to pre-
tion, SCANS lists five workplace competen- sent during a school or job interview.
cies: manage resources (demonstrate ability to
allocate time, money, materials, and space), STUDENT: Go to the workbook and complete
display interpersonal skills (demonstrate abil- the assignment sheet for 17:2, Writing a Cover Let-
ity to work in a team, lead, negotiate, compro- ter and Résumé. Then return and continue with
mise, teach others, and work with individuals the procedure.
PROCEDURE 17:2
2. Re-read the preceding information sec-
Writing a Cover Letter tion on a cover letter and résumés. Read
and Preparing the section on Composing Business Let-
a Résumé ters in Chapter 23:5 of this textbook.
3. Review the sample letters of application
Equipment and Supplies and résumés.
4. Go to the workbook and complete the
Good-quality paper, inventory sheet for résu-
inventory sheet for résumés. Check
més (see workbook), computer with word
dates for accuracy. Be sure that names
processing software and a printer, or type-
are spelled correctly. Use the telephone
writer
book or other sources to check addresses
and zip codes.
Procedure
5. Carefully evaluate all your information.
1. Assemble equipment. Determine the best method of present-
PROCEDURE 17:2
ing your information. Try different ways final copy, checking carefully for errors.
of writing your material. Do not hesitate If possible, ask someone else to proof-
to show several different versions to read your résumé and evaluate it.
your instructor or others and get their
NOTE: Résumés can be copies of the
opinions on which way seems most
original; but be sure the copies are of
effective.
good quality. Cover letters must be orig-
6. Type a rough draft of a cover letter. Fol- inals; they are individually tailored for
low the correct form for letters as shown each potential job, and, therefore, are
in Chapter 23:5 of this textbook. Use not copied.
correct spacing and margins. Check for
correct spelling and punctuation.
7. Type a final cover letter. Be sure it con-
tains the required information. Proof-
read the letter for spelling errors and
other mistakes. If possible, ask someone
else to proofread your letter and evalu-
Practice
ate it.
evaluation sheet for 17:2, Writing a
8. Type a rough draft of your résumé. Posi- Cover Letter and Résumé, to practice
tion the information in an attractive this procedure. When you believe
manner. Be sure that spacing is standard you have mastered this skill, sign
throughout the résumé and margins are the sheet and give it to your
even on all sides. instructor for further action. Also
9. Review your sample résumé. Reword give your instructor your cover letter
any information, if necessary. Be sure all and résumé along with the
information is pertinent and concise. evaluation sheet.
Ask your instructor or others for opin-
ions regarding suggested changes.
10. Type your final résumé. Take care to Final Checkpoint Using the criteria
avoid errors. If you are not a good typist, listed on the evaluation sheet, your
it might be wise to have someone else instructor will grade your cover letter
complete the final draft. Proofread the and résumé.
17:3 INFORMATION areas where certain information is to be placed.

Read instructions that state how the form is to be
Completing Job Application completed. Some forms request that the applicant
type or print all answers. Others request that the
Forms form be completed in the person’s handwriting. If
Even though you provide each potential employer a scanner is available, an application form can be
with a résumé, most employers still require you scanned into a computer so information can be
to complete an application form. Application keyed onto the application. The application can
forms are used by employers to collect specific then be printed. Some health care facilities are
information. Forms vary from employer to using online applications. A computer is used to
employer, but most request similar information. key information into the appropriate spaces. The
Before completing any application form, it is application form is then printed and mailed or
essential that you first read the entire form. Note sent electronically by e-mail to the employer.
538 CHAPTER 17
Be sure you have all the required information ♦ Proofread your completed application. Check
with you when you go for a job interview. Many for completeness, spelling, proper answers to
employers will ask you to complete the applica- questions, and any errors.
tion form at that time. Others will allow you to
take the form home. Still others will even send
♦ If references are requested, be sure to include
all information such as title, address, and tele-
the form to you prior to the interview. The latter
phone number. Before using anyone’s name
two options allow you more time to obtain com-
as a reference, it is best to obtain that person’s
plete information and print or type the form
permission. Be prepared to provide reference
(unless otherwise requested).
information when you go for a job interview.
Basic rules for completing a job application
Most sources suggest listing at least three ref-
form include:
erences on a separate sheet of the same type
♦ Fill out each item neatly and completely. of paper used for the résumé.
♦ Do not leave any areas blank. Put “none” or Even though questions vary on different
“NA” (meaning “not applicable”) when the forms, some basic information is usually re-
item requested does not apply to you. quested on all of them. In order to be sure you
♦ Be sure addresses include zip codes and all have this information, it is useful to take a “wallet
other required information. card” with you. A sample card is included in the
workbook (as Assignment 2). Employers will not
♦ Watch spelling and punctuation. Errors will
be impressed if you have to ask for a telephone
not impress the potential employer.
book to find requested information; you may
♦ Type or print neatly if the application does not appear to be unprepared. Of course, if you are
state otherwise. allowed to take the application home or if it is
♦ Use a black pen if printing. mailed or sent electronically (e-mail) to you,
♦ If possible, scan the application into a com- looking for information would not be a problem.
puter word program, key in all information, Remember that employers use application
check for accuracy, and then print the com- forms as a screening method. To avoid being
pleted application form. Use spell-check if it is eliminated from consideration for a position of
available. This method allows for easy correc- employment, be sure your application creates a
tion of errors. favorable impression.
♦ Make sure all information is legible. STUDENT: Go to the workbook and complete
♦ Do not write in spaces that state “office use the assignment sheets for 17:3, Completing Job
only” or “do not write below this line.” Employ- Application Forms and Wallet Card. Then return
ers often judge how well you follow directions and continue with the procedure.
by your reaction to these sections.
♦ Be sure all information is correct and truthful.
Remember, material can be checked and veri-
fied. A simple half-truth can cost you a job.
PROCEDURE 17:3
Completing Job Procedure
Application Forms 1. Assemble equipment. If a typewriter is
used, be sure the ribbon is of good qual-
Equipment and Supplies ity. If a scanner is available, scan the
application form into the word process-
Typewriter or computer and scanner or pen, ing program of a computer. The appli-
wallet card (sample in workbook), sample cation form can then be completed with
application forms (sample in workbook) the computer and printed on a printer.
PROCEDURE 17:3
2. Complete all information on the wallet sure you are aware of what you are sign-
card. A sample is included in the working and the permission you may be giv-
book (as Assignment 2). Check dates ing. Most employers request permission
and be sure information is accurate. List to contact previous employers and/or
full addresses, zip codes, and names. references, and a verification that infor-
mation is accurate.
3. Review the preceding information sec-
tion on completing job application 9. Recheck the entire application. Be sure
forms. Read additional references, as information is correct and complete.
needed. Note and correct any spelling errors. Be
sure you have answered all of the ques-
4. Read the entire sample application form
tions.
(Assignment 3) in the workbook. Be sure
you understand the information 10. Replace all equipment.
requested for each part. Read all direc-
tions completely.
5. Unless otherwise directed, type all infor-
mation requested. If a typewriter is not
available, use a black ink pen to print all
Practice
information. If a scanner and computer evaluation sheet for 17:3,
are available, scan the application form Completing Job Application Forms,
into a word program. After keying in all to practice this procedure. Obtain
information, the completed application sample job application forms from
can be printed.
your instructor or other sources.
6. Complete all areas of the form. Use When you believe you have
“none” or “NA” as a reply to items that mastered this skill, sign the sheet
do not apply to you. and give it to your instructor for
7. Take care not to write in spaces labeled further action.
“office use only” or “do not write below
this line.” Leave these areas blank.
8. In the space labeled “signature,” sign listed on the evaluation sheet, your
your name. Note any statement that instructor will grade your job applica-
may be printed by the signature line. Be tion form.
application form. To the employer, the interview

17:4 INFORMATION serves at least two main purposes:
Participating in a Job Interview ♦ Provides the opportunity to evaluate you in

person, obtain additional information, and
A job interview is what you are seeking when you ascertain whether you meet the job qualifica-
send a letter of application and a résumé. You tions
must prepare for an interview just as hard as you
did when composing your résumé. A poor inter-
♦ Allows the employer to tell you about the posi-
tion in more detail
view can mean a lost job.
A job interview is usually the last step before Careful preparation is needed before going to
getting or being denied a particular position of an interview. Be sure you have all required infor-
employment. Usually, you have been screened by mation. Your “wallet card,” résumé, and com-
the potential employer and have been selected pleted application form (if you have done one)
for an interview as a result of your résumé and must be ready. If you have completed a career
540 CHAPTER 17
passport or portfolio, be sure to take it to the

interview. If possible, find out about the position
and the agency offering the job. In this way, you
will be more aware of the agency’s needs.
Be sure of the scheduled date and time of the
interview. Know the name of the individual you
must contact and the exact place of the interview.
Write this information down and take it with you.
Dress carefully. It is best to dress conserva-
tively. Coats and ties are still best for men.
Although pantsuits are sometimes acceptable for
women, employers still generally prefer dresses
or skirts. Even though it shouldn’t be the case,
first impressions can affect the employer. All FIGURE 17-4A Shake hands firmly and smile
when you greet an interviewer.
clothes should fit well and be clean and pressed,
if needed. Avoid bright, flashy colors and very
faddish styles.
Check your entire appearance. Hair should
be neat, clean, and styled attractively. Nails
should be clean. Women should avoid wearing
bright nail polish, too much makeup, and per-
fume. Men should be clean shaven. Be sure that
your teeth are clean and your breath is fresh. Jew-
elry should not be excessive. And last but not
least, use a good antiperspirant. When you are
nervous, you perspire.
It is best to arrive 5–10 minutes early for your
interview. Late arrival could mean a lost job. Allow
for traffic, trains blocking the road, and other
complications that might interfere with your
FIGURE 17-4B Sit straight and maintain eye
contact during the interview.
arriving on time.
During the interview, observe all of the fol-
lowing points: ♦ Listen closely to the interviewer. Do not inter-
♦ Greet the interviewer by name when you are rupt in the middle of a sentence. Allow the
introduced. Introduce yourself. Shake hands interviewer to take the lead.
firmly and smile (figure 17-4A). ♦ Answer all questions thoroughly, but don’t go
♦ Remain standing until the interviewer asks into long, drawn-out explanations. Make sure
you to sit. Be aware of your posture and sit your answers show how you are qualified for
straight. Keep both feet flat on the floor or the job.
cross your legs at the ankles only. ♦ Do not smoke, chew gum, or eat candy during
♦ Use correct grammar. Avoid using slang the interview.
words. ♦ Smile but avoid excessive laughter or gig-
♦ Speak slowly and clearly. Don’t mumble. gling.
♦ Be polite. Practice good manners. ♦ Be yourself. Do not try to assume a different
personality or different mannerisms; doing so
♦ Maintain eye contact (figure 17-4B). will only increase your nervousness.
Avoid looking at the floor, ceiling, or
away from the interviewer. Looking at the ♦ Be enthusiastic. Display your positive atti-
middle of the interviewer’s forehead or at the tude.
tip of the interviewer’s nose can sometimes ♦ Avoid awkward habits such as swinging your
help when you are nervous and experiencing legs, jingling change in your pocket, waving
difficulty with direct eye contact. your hands or arms, or patting at your hair.
♦ Never discuss personal problems, finances, or

other situations in an effort to get the job. This
usually has a negative effect on the inter-
viewer.
♦ Do not criticize former employers or degrade
them in any way.
♦ Answer all questions truthfully to the best of
your ability.
♦ Think before you respond. Try to organize the
information you present.
♦ Be proud of yourself, to a degree. You have
skills and are trained. Make sure the inter-
viewer is aware of this. However, be sure to
show a willingness to learn and to gain addi-
tional knowledge.
♦ Do not immediately question the employer FIGURE 17-5 After a job interview, send a thank-
about salary, fringe benefits, insurance, and you note, letter, or e-mail to the employer.
other similar items. This information is usu-
ally mentioned before the end of the inter-
view. If the employer asks whether you have questions and your responses to them. The fol-
any questions, ask about the job description lowing is a suggested list of questions to review.
or responsibilities, type of uniform required, Additional questions may be found in any book
potential for career growth, continuing educa- on job interviews.
tion or in-service programs, and job orienta-
tion. These types of questions indicate a ♦ Tell me a little about yourself. (Note: Stick to
sincere interest in the job rather than a “What’s job-related information.)
in it for me?” attitude. ♦ What are your strong points/weak points?
♦ Do not expect a definite answer at the end of (Note: Be sure to turn a weakness into a posi-
the interview. The interviewer will usually tell tive point. For example, say, “One of my weak-
you that he or she will contact you. nesses is poor spelling, but I use a dictionary
to check spelling and try to learn to spell ten
♦ Thank the interviewer for the interview as you
new words each week.”)
leave. If the interviewer extends a hand, shake
hands firmly. Smile, be polite, and exit with ♦ Why do you feel you are qualified for this posi-
confidence. tion?
♦ Never try to extend the interview if the ♦ What jobs have you held in the past? Why did
interviewer indicates that he or she is ready to you leave these jobs? (Note: Avoid criticizing
end it. former employers.)
After the interview, it is best to send a follow- ♦ What school activities are you involved in?
up note, letter, or electronic message (e-mail) to ♦ What kind of work interests you?
thank the employer for the interview (figure ♦ Why do you want to work here?
17-5). You may indicate that you are still inter-
ested in the position. You may also state that you ♦ What skills do you have that would be of
are available for further questioning. When an value?
employer is evaluating several applicants, a ♦ What is your attitude toward work?
thank-you note is sometimes the deciding factor ♦ What do you want to know about this job
in who gets the job. opening?
Because you may be asked many different
questions during an interview, it is impos- ♦ What were your favorite subjects in school and
sible to prepare all answers ahead of time. How- why?
ever, it is wise to think about some potential ♦ What does success mean to you?
542 CHAPTER 17
♦ How do you manage your time? but firm in your refusal. A statement such as “I
prefer not to answer that question” or “Can I ask
♦ What is your image of the ideal job?
you how this would affect the job we are discuss-
♦ How skilled are you with computers? ing?” is usually sufficient.
♦ What are the three most important things to At the end of the interview, you may be
you in a job? asked to provide proof of your eligibility to
work. Under the Bureau of Immigration Reform
♦ Do you prefer to work alone or with others?
Act of 1986, employers are now required by fed-
Why?
eral law to ask you to complete an Employment
♦ How many days of school did you miss last Eligibility Verification Form I-9. This form helps
year? the employer verify that you are legally entitled to
♦ What do you do in your spare time? work in the United States. To complete this form,
you must provide documents that indicate your
♦ Do you have any plans for further education?
identity. A birth certificate, passport, and/or
Any questions that may reflect discrimina- immigration card can be used for this purpose.
tion or bias do not have to be answered You must also have a photo identification, such
during a job interview. Federal law prohibits disas a driver’s license, and a social security card.
crimination with regard to age, cultural or ethnic The employer must make copies of these docu-
background, marital status, parenthood, disabil- ments and include them in your file. Having these
ity, religion, race, and sex. Employers are aware forms readily available shows that you are pre-
that it is illegal to ask questions of this nature, and pared for a job.
the large majority will not ask such questions. If
an employer does ask a question of this nature,
however, you have the right to refuse to answer. STUDENT: Go to the workbook and complete
An example of this type of question might be, “I the assignment sheet for 17:4, Participating in a
see you married recently. Do you plan to start Job Interview. Then return and continue with the
having children in the next year or two?” Be polite procedure.
PROCEDURE 17:4
interviewed. Make sure they will not
Participating in a Job interfere with the interview.
Interview 3. The interviewer should be seated at the
desk and have a list of possible ques-
Equipment and Supplies tions to ask during the interview.
Desk, two chairs, evaluation sheets, lists of 4. Play the role of the person being inter-
questions viewed. Prepare for this role by doing
the following:
Procedure a. Be sure you have all necessary infor-
mation. Prepare your wallet card,
1. Assemble equipment. Role-play a mock résumé, job application form, and/or
interview with four persons. Arrange for career passport or portfolio.
two people to evaluate the interview,
one person to be the interviewer, and b. Dress appropriately for the interview
you to be the interviewee. (as outlined in the preceding infor-
mation section).
2. Position the two evaluators in such a
way that they can observe both the c. Arrive at least 5–10 minutes early for
interviewer and you, the person being the interview.
PROCEDURE 17:4
5. When you are called for the interview, 12. Check your performance by looking at
introduce yourself. Be sure to refer to the evaluation sheets completed by
the interviewer by name. the two observers. Study suggested
changes.
6. Sit in the chair indicated. Be aware of
your posture, making sure to sit straight. 13. Replace all equipment.
Keep your feet flat on the floor or cross
your legs at the ankles only.
7. Listen closely to the employer. Answer
all questions thoroughly and com-
pletely. Think before you speak. Orga-
nize your information.
Practice
8. Maintain eye contact. Avoid distracting Go to the workbook and use the
mannerisms. evaluation sheet for 17:4,
9. Use correct grammar. Avoid slang Participating in a Job Interview, to
expressions. Speak in complete sen- practice this procedure. When you
tences. Practice good manners. believe you have mastered this skill,
10. When you are asked whether you have
any questions, ask questions pertaining
to the job responsibilities. Avoid a series
of questions on salary, fringe benefits,
vacations, time off, and so forth.
11. At the end of the interview, thank the Final Checkpoint Using the criteria
interviewer for his or her time. Shake listed on the evaluation sheet, your
hands as you leave. instructor will grade your performance.
17:5 INFORMATION ♦ Net income: This is commonly referred to as

“take-home pay.” It is the amount of money
Determining Net Income available to you after all payroll deductions
have been taken out of your salary. Some com-
Obtaining a job means, in part, that you will
mon deductions are Social Security tax, fed-
be earning your own money. This often
eral and state taxes, and city taxes. Other
means that you will be responsible for your own
deductions may include payroll deductions
living expenses. To avoid debt and financial cri-
such as those for United Appeal, medical or
sis, it is important that you learn about managing
life insurance, union dues, and other similar
your money effectively, including understanding
items.
how to determine net income.
The term income usually means money that
To determine gross income, simply multiply
you earn or that is available to you. However, the
your wage per hour times the number of hours
amount you actually earn and the amount you
worked. For example, if you earn $9.00 per hour
receive to spend may vary. The following two
and work a 40-hour week, 9 40 $360.00. In
terms explain the difference.
this example, then, $360.00 would be your gross
♦ Gross income: This is the total amount of income.
money you earn for hours worked. It is the To determine net income, you must first
amount determined before any deductions determine the amounts of the various deductions
have been taken out of your pay. that will be taken out of your gross pay. Deduc-
544 CHAPTER 17
tion percentages usually vary depending on your ♦ Deduction for city tax is approximately 1 per-
income level. You can usually determine approxi- cent.
mate deduction percentages and, therefore, your
approximate net income by referring to tax charts. 1%, or 0.01, 360 3.60 3.60
Tax charts for federal taxes are available on the 295.20
Internet at www.irs.gov. Tax charts for cities and
states can usually be found on the treasurer’s
♦ Deduction for F.I.C.A., or Social Security tax,
includes 6.2 percent of the first $102,000 in
Internet site for the particular city or state. Never
income and a Medicare deduction of 1.45 per-
hesitate to ask your employer about deduction
cent of the total in income, for a total deduc-
percentages. It is your responsibility to check
tion of 7.65 percent.
your own paycheck for accuracy. Starting with
the example of gross pay of $360.00, the following
shows how net pay may be determined. 7.65%, or 0.0765, 360 27.54 –27.54
267.66
Gross Pay $360.00
♦ Net income after taxes, then, would be $267.66.
♦ Deduction for federal tax in this income range Therefore, before you even receive your pay-
is usually approximately 15 percent. Check tax check, $92.34 will be deducted from it. Addi-
tables for accuracy. tional deductions for insurance, union dues,
contributions to charity, and other items may
15%, or 0.15, 360 $54.00 54.00 also be taken out of your gross pay.
306.00
In order to manage your money effectively, it
♦ Deduction for state tax is approximately 2 per- is essential that you be able to calculate your net
cent. income. Because this is the amount of money you
will have to spend, it will to some extent deter-
2%, or 0.02, 360 $7.20 7.20 mine your lifestyle.
298.80
STUDENT: Read and complete Procedure 17:5,
Determining Net Income.
PROCEDURE 17:5
assigned by your instructor. Multiply
Determining Net this amount by the number of hours you
Income work per week. This is your gross weekly
pay.
Equipment and Supplies 4. If your instructor has federal tax tables,
read the tax tables to determine the per-
Assignment sheet for 17:5, Determining Net
centage, or amount of money, that will
Income; pen or pencil
be withheld for federal tax. If tax tables
are not available, look on the Internet at
Procedure www.irs.gov or check with your employer
to obtain this information.
1. Assemble equipment. If a calculator is
available, you may use it to complete NOTE: The average withholding tax for
this assignment. an initial income bracket is usually
approximately 15 percent. If you cannot
2. Read the instructions on the assignment
find the exact amount or percentage,
sheet in the workbook for 17:5, Deter-
use this amount (0.15) for an approxi-
mining Net Income. Use the assignment
mate determination.
sheet with this procedure.
5. Multiply the percentage for federal tax
3. Determine your wage per hour by using
times your gross weekly pay to deter-
your salary in a current job or an amount
PROCEDURE 17:5
mine the amount deducted for federal and 1.45 percent of total income for
tax. Medicare. Use this total of 7.65 percent,
or 0.0765, if you cannot obtain another
6. Determine the deduction for state tax
percentage.
by reading your state tax tables, check-
ing the state treasurer’s site on the Inter- 11. List the amounts for any other deduc-
net, or by consulting your employer. tions. Examples include insurance,
charitable donations, union dues, and
NOTE: An average state tax is 2 percent.
similar items.
If you cannot find the exact amount or
percentage, use this amount (0.02) for 12. Add the amounts determined for federal
an approximate determination. tax, state tax, city/corporation tax, social
security, and other deductions together.
7. Multiply the percentage for state tax by
your gross weekly pay to determine the 13. Subtract the total amount for deduc-
amount deducted for state tax. tions from your gross weekly pay. The
amount left is your net, or take-home,
8. Determine the deduction for any city or
pay.
corporation tax by reading the city/cor-
poration tax tables, checking the city/ 14. Recheck any figures, as needed.
corporation treasurer’s site on the Inter-
net, or consulting your employer.
NOTE: An average city/corporation tax
is 1 percent. If you cannot find the exact
amount or percentage, use this amount
(0.01) for an approximate determina-
tion.
Practice
9. Multiply the percentage for city/corpo- evaluation sheet for 17:5,
ration tax by your gross weekly pay to Determining Net Income. Practice
determine the amount deducted for determining net income according
city/corporation tax. to the criteria listed on the
10. Check the current deduction for F.I.C.A., evaluation sheet. When you believe
or Social Security and Medicare, by you have mastered this skill, sign
checking the Social Security Internet the sheet and give it to your
site or asking your employer for this instructor for further action.
information. Determine the deduction
for F.I.C.A. by multiplying your gross
weekly pay by this percentage.
NOTE: In 2008, the F.I.C.A. rate was 6.2 listed on the evaluation sheet, your
percent of the first $102,000 in income instructor will grade your performance.
17:6 INFORMATION A budget usually consists of two main types

of expenses: fixed expenses and variable expenses.
Calculating a Budget Fixed expenses include items such as rent or
In order to use your net income wisely, it is house payments, utilities, food, car payments,
best to prepare a budget. A budget is an and insurance payments. Variable expenses
itemized list of living expenses. It must be realis- include items such as entertainment, clothing
tic to be effective. purchases, and donations.
546 CHAPTER 17
The easiest way to prepare a budget is to sim- ♦ Clothing: 3–10 percent

ply list all anticipated expenses for a one-month
period. Then determine your net monthly pay.
♦ Personal care (including soap, toothpaste,
laundry detergents, cosmetics, etc.): 2–4 per-
Allow a fair percentage of the net monthly pay for
cent
each of the budget items listed.
Savings should be incorporated into every ♦ Miscellaneous (including travel, child care,
budget. If saving money is regarded as an obliga- entertainment, gifts, etc.): 1–4 percent
tion, it is easier to set aside money for this pur- ♦ Savings: 5–9 percent
pose. When an emergency occurs, money is then
available to cover the unexpected expenditure.
It is important to remember that these percent-
Some payments are due once or twice a year.
ages and line items are just suggested guidelines.
An example is insurance payments. To be realis-
Each individual must determine his or her own
tic, a monthly amount should be budgeted for
needs and allocate monies accordingly. However,
this purpose. To determine a monthly amount,
MMI does state that personal debt should not
divide the total yearly cost for the insurance by
exceed 10–20 percent of net income. Financial
12. Then budget this amount each month. In this
difficulties usually occur when debt exceeds this
way, when insurance payments are due, the
limit.
money is available for payment, and one month’s
It is important that budgeted expenses do not
budget will not have to bear the full amount of
exceed net monthly income. It may sometimes
the insurance payment.
be necessary to limit expenses that are not fixed.
Money Management International (MMI), a
Entertainment, clothing purchases, and similar
nonprofit consumer counseling organization,
items are examples of expenses that can be lim-
recommends that the following percentage
ited.
ranges of total net income be used while prepar-
The final step is to live by your budget and
ing a realistic budget:
avoid any spending over the allotted amounts.
♦ Housing: 20–35 percent This is one way to prevent financial problems and
♦ Food: 15–30 percent excessive debt. If your fixed expenses or net
♦ Utilities: 4–7 percent income increases, you will have to revise your
budget. Remember, creating a budget leads to
♦ Transportation (including car loan, insurance,
careful management of hard-earned money.
gas, and maintenance): 6–20 percent
♦ Insurance (including health, life, and/or dis-
ability): 4–6 percent
♦ Health (including prescriptions, eye care, den-
STUDENT: Read Procedure 17:6, Calculating
a Budget. Then go to the workbook and complete
tal care): 2–8 percent
the corresponding assignment sheet.
PROCEDURE 17:6
2. Go to the workbook and read the instruc-
Calculating a Budget tions on the assignment sheet for 17:6,
Calculating a Budget.
Equipment and Supplies 3. Determine your fixed expenses for a
Assignment sheet for 17:6, Calculating a Bud- one-month period. This includes
get; pen or pencil amounts you must pay for rent, utilities,
loans, charge accounts, insurance, and
Procedure similar items. List these expenses.
4. Determine your variable expenses for a
1. Assemble equipment. If a calculator is one-month period. This includes
available, you may use it to complete amounts for clothing purchases, per-
this procedure.
PROCEDURE 17:6
sonal items, donations, entertainment, 10. When the expense total in your budget
and similar items. List these expenses. equals your monthly net income, you
have a balanced budget. Live by this
5. List any other items that must be
budget and avoid any expenditures not
included in your monthly budget. Be
listed on the budget.
sure to list a reasonable amount for each
item. 11. Replace all equipment.
6. Determine a reasonable amount for
savings. Many people prefer to set aside
a certain percentage of their net monthly
pay as savings.
7. Determine your net monthly pay. Dou-
ble-check all figures for accuracy.
Practice
8. Add all of your monthly budget expenses evaluation sheet for 17:6,
together. The sum represents your total Calculating a Budget, to practice
expenditures per month. this procedure. When you believe
9. Compare your expense total to your net you have mastered this skill, sign
monthly income. If your expense total is the sheet and give it to your
higher than your net income, you will instructor for further action. Give
have to revise your budget and reduce your instructor a completed budget
any expenses that are not fixed. If your along with the evaluation sheet.
expense total is lower than your net
income, you may increase the dollar
amounts of your budget items. If the
other figures in your budget are realis- Final Checkpoint Using the criteria
tic, it may be wise to increase the dollar listed on the evaluation sheet, your
amount of savings. instructor will grade your budget.
CHAPTER 17 SUMMARY having a positive attitude, working well with oth-

ers, taking responsibility for your actions, and
being willing to learn. Without good job-keep-
Even if an individual is proficient in many skills, ing skills, no amount of knowledge will help you
it does not necessarily follow that the individual keep a job.
will obtain the “ideal” job. Just as it is important One of the first steps in obtaining a job in-
to learn the skills needed in your chosen health volves preparing a cover letter and a résumé.
care career, it is important to learn the skills nec- These are the “press releases” that tell a poten-
essary to obtain a job. tial employer about your skills and abilities. A
Job-keeping skills important to an employer properly prepared résumé will help you obtain
include using correct grammar in both oral and an interview.
written communications, reporting to work on It is important to prepare for an interview.
time and when scheduled, being prepared to Careful consideration should be given to dress
work, following correct policies and procedures, and appearance. Answers should be prepared
548 CHAPTER 17

A bravery gene?
Anxiety and fear have been felt by every human being. However, some individuals are so
anxious or fearful they are not able to function within society. For example, individuals with
agoraphobia have an abnormal fear of being helpless in a situation from which they cannot
escape, so they stay in an environment in which they feel secure. Many agoraphobic people
never leave their homes; they avoid all public or open places. Scientists are not really certain
how fear works in the brain, so conditions such as these are difficult to treat.
Recently, scientists working with mice found that by removing a single gene, they could
turn normally cautious animals into brave animals that were more willing to explore an
unknown territory and were less intimidated by dangers. By analyzing brain tissue, scien-
tists located a gene in a tiny prune-shaped region of the brain called the amygdala, an area
of the brain that is extremely active when animals or humans are afraid or anxious. This
gene produces a protein called stathmin, which is highly concentrated in the amygdala but
very hard to detect in other areas of the brain. Scientists removed this stathmin gene and
bred a line of mice that were all missing this gene. Tests showed that this breed of mice was
twice as willing to explore unknown territories as unaltered mice. In addition, if the mice
were trained to expect a small electrical shock after being presented with a stimulus such as
a sound or sight, this group of mice did not seem as fearful when the sound or sight was
given. Researchers are theorizing that stathmin helps form fearful memories in the amyg-
dala of the brain, the area where unconscious fears seemed to be stored. If the production of
stathmin could be halted or inhibited by medication, it is possible that fears would not be
stored as unconscious memories. This would greatly decrease an individual’s anxieties
because unconscious fears are a major cause of anxiety. Think of all of the people whose
lives are affected by anxiety and fear. If their anxieties and fears could be decreased or elim-
inated, they could lead normal healthy lives.
for common interview questions. The appli-

cant should also try to learn as much as possible INTERNET SEARCHES
about the potential employer; this way, the ap-
plicant will be able to match his or her skills and Use the suggested search engines in Chapter 12:4
abilities to the needs of the employer. Finally, of this textbook to search the Internet for addi-
practice completing job application forms. A tional information on the following topics:
neat, correct, and thorough application form 1. Components of a job search: find information
will also help you get a job. on letters of application or cover letters, résu-
Certain other skills become essential when més, job interviews, and job application forms
a person has a job. Everyone should be able to
3. Requirements of employers: locate information
calculate gross and net income. In addition, ev-
on skills and qualities that employers desire
eryone should be able to develop a budget based
on needs and income. Having and following a 4. Job search: look for sites that provide informa-
budget makes it more likely that money earned tion on employment opportunities. For spe-
will be spent wisely and minimizes the chance cific health care careers, look for opportunities
of debt. Learn the job-seeking and job-keeping under organizations for the specific career.
skills well. They will benefit you throughout your Also check general sites such as monster.com,
life as you seek new positions of employment job-listing.com, jobsleuth.com, hotjobs.yahoo.
and advance in your chosen health career. com, careerbuilder.com, and joblocator.com.
4. Salary and wages: check sites such as the 4. State six (6) basic principles that must be
Internal Revenue Service (IRS), state and local followed while completing a job application
tax departments, and Social Security Adminis- form.
tration for information on taxes and tax rates;
5. Create answers for the following interview
also locate sites on money management,
questions.
budgeting, and fiscal or financial management
a. Why do you believe you are qualified for this
for information on how to manage money
job?
b. Why do you want to leave your current job?
REVIEW QUESTIONS c. Tell me about two or three of your major
accomplishments and why you feel they are
important.
1. Choose four (4) job-keeping skills that you
6. You have obtained a job and will receive a
believe you have mastered. Write a paragraph
salary of $8.20 per hour. Calculate the
describing why you believe you have mastered
following:
these skills.
a. Gross pay for a 40-hour week
2. What is the main purpose of a letter of applica- b. Federal tax deduction of 15%
tion or cover letter? When is it used? c. State tax deduction of 3%
3. List the main sections of a résumé and briefly d. City tax deduction of 0.5%
describe the information that should be e. FICA or social security deduction of 7.65%
included in each section. f. Net pay after above deductibles
PART 2 Special Health
Care Skills
Introduction
This part is divided into six major chapters. The topics are
designed to provide you with the basic knowledge and skills
required to perform a wide variety of procedures used in
specific health careers. Before you start a chapter, read the
chapter objectives so you will know exactly what is expected
of you. The objectives identify the competencies you should
have mastered on completing the chapter.
For each procedure discussed in this part, you will find
information and procedure sections in the textbook. In the
workbook, you will find two types of sheets: assignment
sheets and evaluation sheets. Following are brief explana-
tions of these main components of the textbook and work-
book.
1. Information Sections (Textbook): The information sec-
tions are designed to provide the basic knowledge you
must have to perform the procedures. The sections
explain why things are done, give necessary facts, and
stress key points that should be observed. Each infor-
mation section refers you to a specific assignment sheet
in the workbook.
2. Assignment Sheets (Workbook): The assignment sheets
provide review of the main facts and related informa-
tion about the procedures. After you have read each
information section in the text, try to answer the ques-
tions on the assignment sheet. Then refer back to the
information section to see whether your answers are
correct. Let your instructor grade your completed
assignment sheet. Note and learn from any points that
were incorrect. Be sure you understand all information
before performing the procedure.
3. Procedure Sections (Textbook): The procedure sections provide step-by-step instructions
on how to perform the procedures. Follow the steps while you practice the procedures.
Each procedure lists the equipment and supplies you will need. Be sure you have all the
necessary equipment and supplies before you begin.
At times you will see one of three words within the procedure sections: Note, Caution, and
Checkpoint. Note means to carefully read the comment following. These comments usually
stress points of knowledge or explain why certain techniques are used. Caution means that
a safety factor is involved and that you should proceed carefully while doing this step to
avoid injury to yourself or the patient. Checkpoint means to ask your instructor to check
you at this point in the procedure. Checkpoints are usually located at critical points in the
procedures. Each procedure section in this part of the text refers you to a specific evalua-
tion sheet in the workbook.
4. Evaluation Sheets (Workbook): Each evaluation sheet contains a list of the criteria on which
you will be tested when you have demonstrated that you have mastered a particular proce-
dure. Use these sheets as you practice the procedures. Make sure that your performance
meets the established standards. When you believe you have mastered a particular proce-
dure, sign the evaluation sheet and give it to your instructor. Your instructor will grade you
by using the listed criteria and checking each step against your performance.
As was the case in Part 1, you will notice icons throughout this part of the textbook. The
purpose of these icons is to accentuate particular factors or denote specific types of knowledge.
The icons and their meanings are as follows:
Observe Standard
Precautions
Science Skill
Career Information
Caution
on Federal Law
Math Skill Technology
Copyright 2009 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
30216_18_Ch18_550-647.indd 551 1/23/08 7:09:31 PM

CHAPTER 18 Dental Assistant
Skills
Chapter Objectives
After completing this chapter, you should be able to:
♦ Name all the structures and tissues of a tooth
Observe Standard ♦ Identify deciduous and permanent teeth
Precautions ♦ Identify teeth by the Universal/National
Numbering System and the FDI System
♦ Identify surfaces of the teeth
♦ Chart conditions of teeth
♦ Operate and maintain dental equipment
♦ Identify dental instruments and set up dental
Safety—Proceed with trays for oral examination, amalgam restoration,
Caution composite restoration, and surgical extraction
♦ Position a patient in a dental chair
♦ Demonstrate the Bass method of brushing
OBRA Requirement—Based ♦ Demonstrate flossing technique
on Federal Law
♦ Prepare alginate and take an impression from
dentures
Math Skill
♦ Prepare rubber base impression material and
load a syringe
♦ Pour plaster and stone models
Legal Responsibility ♦ Make a custom tray
♦ Describe proper maintenance of anesthetic
carpules and an aspirating syringe
Science Skill ♦ Load an anesthetic aspirating syringe
♦ Mix cements and bases for dental use
♦ Mix amalgam and load the amalgam carrier
Career Information
♦ Mix composite for restorations
♦ Develop dental radiographs
Communications Skill ♦ Mount full-mouth and bite-wing radiographs
Technology
Dental Assistant Skills 553
KEY TERMS
air compressor dentin periapical films
alginate (ahl⬘-jih-nate⬙) dentitions (per-ree-ape⬘-ih-kal)
alveolar process distal permanent (succedaneous)
(al-vee⬘-o-lar) doctor’s cart teeth
amalgam (ah-mahl⬘-gam) enamel periodontal ligament
anesthesia (an-es-thee⬘-sha) Federation Dentaire (pear⬙-e-o-don⬘-till)
Note: th as in “thin” International (FDI) periodontium
anesthetic carpules System plaque (plak⬘)
(cartridges) gingiva (jin⬘-jih⬙-vah) plaster
anterior halitosis (hal⬙-ih-toe⬘-sis) point angles
apex high-speed handpiece posterior
apical foramen high-velocity oral evacuator primary (deciduous) teeth
aspirating syringe impression prophylaxis angle (proh⬙-fill-
assistant’s cart incisal ax⬘-sis an⬘-gull)
base incisors pulp
bicuspids labial (lab⬘-ee⬙-ahl) quadrant
bite-wings line angles radiographs
buccal (buck⬘-kal) liner radiolucent
burs lingual (lynn⬘-gwal) (ray⬙-dee-oh-lew⬘-sent)
carious lesions (caries) low-speed handpiece radiopaque
(care⬘-ee⬙-us lee⬘-shunz) (ray⬙-dee-oh-payk⬘)
mandibular
cavity restoration
maxillary
cement rheostats (ree⬘-oh-stats⬙)
mesial (me⬘-ze-ahl)
cementum root
model
cervix rubber base (polysulfide)
molars
composite (kom-poz⬘-it) saliva ejector
occlusal (oh-klew⬘-sal)
contra angle silicone
occlusal films
crown stone
odontology
cuspids temporary
oral-evacuation system
cuspidor tri-flow (air–water) syringe
panoramic
custom trays Universal/National
pedodontic (child) films
dental chair Numbering System
(pee-doe-don⬘-tick)
dental light
554 CHAPTER 18
CAREER HIGHLIGHTS
Dental assistants work under the supervision of doctors, called dentists, and they are impor-
tant members of the dental health care team. Educational requirements vary from state to
state, but can include on-the-job training, one- or two-year health occupations education
programs, and/or an associate’s degree.
Certification is available through the Dental Assisting National Board (DANB) after an
individual has taken a 104-hour course approved by the DANB. Graduation from an
accredited program of dental assisting or two years of full-time employment as a dental
assistant is required before an individual can take the certification examination. The duties
of dental assistants vary depending on the size and type of practice, and on the dental prac-
tice laws of the state in which they work. Each state has a dental practice act that governs
which duties dental assistants can perform. It is the responsibility of the dental assistant to
know and follow the state regulations. In addition to the knowledge and skills presented in
this chapter, dental assistants must also learn and master skills such as:
◆ Presenting a professional ◆ Comprehending human ◆ Promoting good nutrition
appearance and attitude anatomy, physiology, and and a healthy lifestyle to
◆ Obtaining knowledge
pathophysiology with an maintain dental health
regarding health care emphasis on oral ◆ Utilizing computer skills
delivery systems, anatomy and physiology
◆ Performing administrative
organizational structure, ◆ Observing all safety
and teamwork precautions the telephone, scheduling
◆ Meeting all legal ◆ Practicing all principles of appointments, preparing
responsibilities infection control correspondence,
◆ Communicating ◆ Taking and recording vital
completing insurance
effectively signs forms, maintaining
accounts, recording dental
◆ Being sensitive to and ◆ Administering first aid histories, and maintaining
respecting cultural and cardiopulmonary patient records
diversity resuscitation
◆ Ordering and maintaining
◆ Learning dental supplies and materials
terminology
18:1 INFORMATION a newborn has approximately 44 teeth buds at

various stages of development. When a child is
Identifying the Structures approximately 6 months old, these teeth buds
begin to erupt into the mouth to form the pri-
and Tissues of a Tooth mary dentition. When a child is approximately 2
An understanding of the basic structures to 3 years old, all of the 20 primary teeth will have
and tissues of a tooth is essential for a den- erupted. These teeth maintain proper spacing for
tal assistant. Odontology is the study of the the permanent, or succedaneous, teeth and are
anatomy, growth, and diseases of the teeth. Teeth used for mastication and speech. Between the
are accessory organs of the digestive tract that aid ages of 6 and 12 years, all of the primary teeth are
in the mastication, or chewing, of food. Individu- lost and are replaced by the permanent dentition.
als have two dentitions, or sets, of teeth: a pri- These permanent teeth begin to erupt when a
mary, or deciduous, dentition, and a permanent, child is approximately 5–6 years old. They con-
or succedaneous, dentition (figure 18-1). At birth, tinue erupting and replacing primary teeth until
Central incisor
(7–8 years)
Lateral incisor
(8–9 years)
Cuspid (10–12 years)
First premolar, or bicuspid

(10–12 years)
Second premolar, or bicuspid
Central incisor (10–12 years)
(6–10 months)
First molar
Lateral incisor (9–12 months) (6–7 years)
Cuspid (16–20 months) Maxillary
Maxillary Second molar
First molar (12–18 months) (Upper)
(12–13 years)
(Upper) Second molar Teeth
Teeth (22–32 months) Third molar (17–22 years)
Third molar (17–22 years)

Mandibular Second molar
(Lower) (20–30 months) Second molar (11–13 years) Mandibular
Teeth (Lower)
First molar (12–18 months) First molar (6–7 years) Teeth
Cuspid (16–20 months)
Lateral incisor Second premolar,
(7–11 months) or bicuspid (10–12 years)
Central incisor (6–10 months) First premolar,
or bicuspid (10–12 years)
Cuspid (9–10 years)
Lateral incisor
(6–8 years)
Central incisor
(5–7 years)
A. Primary Teeth B. Permanent Teeth

FIGURE 18-1 Eruption times of (A) primary (deciduous) and (B) permanent (succedaneous) teeth.
the individual reaches approximately 17–20 years Enamel

of age, when the third molars, or wisdom teeth,
erupt. Most of the 32 teeth in the permanent den-
Dentin
tition are in place by 12 years of age. A child 5–12
years old who has both primary and permanent Pulp in pulp
Crown chamber
teeth erupted in the mouth has a mixed denti-
Cemento-
tion. Cervix enamel junction
Every tooth in both the primary and perma-
Free
nent dentitions has four main sections, or divi- gingiva
Root
sions: the crown, the root, the cervix, and the Alveolar
apex (figure 18-2): process
Attached
♦ Crown: This is the section of the tooth that is gingiva
visible in the mouth. It is protected on the Cementum
outside by the tissue called enamel. Pulp canal
Apex with apical
♦ Root: This is the section of the tooth below the foramen
Periodontal
gingiva, or gums. It is covered on the outside by ligament
the tissue called cementum. The root is nor- FIGURE 18-2 The structures and tissues of a
mally not visible in the mouth; it helps anchor, tooth.
556 CHAPTER 18
or hold, the tooth in the bony socket of the jaw. The periodontium consists of those struc-
A tooth may have a single root or multiple tures that surround and support the teeth, and
roots. If it has two roots, it is called bifurcated; includes the alveolar process, the periodontal
if it has three roots, it is called trifurcated. ligament, and the gingiva:
♦ Cervix: This is also called the neck, cervical ♦ Alveolar process or ridge: This is the bone
line, or cemento-enamel junction, because it is tissue of the maxilla (upper jawbone) and
the area where the enamel covering the crown mandible (lower jawbone) that surrounds the
meets the cementum covering the root. It is roots of the teeth. It contains a series of sock-
the narrow section where the crown joins with ets, or alveoli—one for each tooth. Although
the root. the root of the tooth sits in the alveolus and is
supported by it, the tooth does not touch the
♦ Apex: This is the tip of the root of the tooth. It
bone because the periodontal ligament sus-
contains an opening called the apical fora-
pends it in place.
men, through which nerves and blood vessels
enter the tooth. ♦ Periodontal ligament: This consists of
dense fibers of connective tissue that attach to
Each tooth is made of four main tissues:
the cementum of the tooth and to the alveo-
enamel, cementum, dentin, and pulp (refer to
lus. The periodontal ligament supports or sus-
figure 18-2):
pends the tooth in the socket. It acts as a shock
♦ Enamel: This is the hardest tissue in the body absorber and prevents the tooth from resting
and covers the outside of the crown. It is made on or rubbing against the bone during chew-
up mainly of calcium and phosphorus, and ing. The periodontal ligament also contains
forms a protective layer for the tooth. Once a nerves and blood vessels that provide nour-
tooth is fully developed, the enamel cannot ishment, aid in the production of cementum,
grow or repair itself. and produce sensation when pressure is
applied to the tooth.
♦ Cementum: This is the hard, bonelike tissue
that covers the outside of the root. In addition ♦ Gingiva, or gums: These are made of epithe-
to providing a thin layer of protection, it also lial tissue covered with mucous membrane.
helps hold the tooth in place. Cementum is They cover the alveolar bone and surround
formed throughout the life of the tooth. the teeth. The gingiva that surrounds the cer-
vix of a tooth and fills the interproximal spaces
♦ Dentin: This is the tissue that makes up the (spaces between the teeth) is called free gin-
main bulk of the tooth. It lies under the enamel giva because it is not attached to the tooth.
of the crown and under the cementum of the The space between the free gingiva and the
root. It is a bonelike substance that is softer tooth is the gingival sulcus. Dental floss is
than enamel but harder than cementum and used to clean this area of the tooth. Gingiva
bone. Although it has no nerves, it carries sen- attached to the alveolar bone is called attached
sations of pain and temperature to the pulp. gingiva.
Dentin is a living tissue that is capable of lim-
ited repair and continued growth. The internal The supporting structures and tissues of the teeth
surface of dentin forms the wall of the pulp are meant to last a lifetime. However, disease can
chamber. affect the teeth and supporting structures just as
it can affect other organs of the body. Dental care
♦ Pulp: This is the soft tissue located in the
is directed toward preventing and treating dental
innermost area of the tooth. It is made up of
disease and preserving and prolonging the life of
blood vessels and nerves held in place by con-
the teeth. The information and procedures pre-
nective tissue. The section of pulp located in
sented in this chapter are all methods of prevent-
the crown is called the pulp chamber, and the
ing and treating dental disease.
section located in the root is called the pulp
canal (or root canal ) . The pulp chamber and
the pulp canal create a space in the center of STUDENT: Go to the workbook and complete
the tooth known as the pulp cavity. The pulp the assignment sheet for 18:1, Identifying the
provides sensation and nourishment for the Structures and Tissues of a Tooth. Then return and
tooth and helps produce dentin. continue with the procedure.
PROCEDURE 18:1
c. cervix
Identifying the
Structures and Tissues d. apex and apical foramen
of a Tooth 5. Use an anatomical model or chart of a

tooth to identify and describe the func-
tion of each of the following tissues of a
Equipment and Supplies tooth:
Anatomical model or chart of the structures a. enamel
and tissues of a tooth, paper, and pen or b. cementum
pencil
c. dentin
Procedure d. pulp
6. Use an anatomical model or chart of a
1. Assemble equipment. tooth to identify and state the function
2. Wash hands. of each of the following structures of the
periodontium:
3. Review Information section 18:1 and
then answer the following questions by a. alveolar process
writing the answers or discussing the b. periodontal ligament
information with a lab partner:
c. gingiva
a. Differentiate between primary (de-
7. Without looking at the model or chart,
ciduous) and permanent (succeda-
draw a tooth and label all of the divi-
neous) dentitions.
sions, tissues, and supporting struc-
b. State the ages when primary teeth tures. Then compare your drawing to
begin to erupt in the mouth and the model or chart. Check it for accu-
when they finish erupting. racy and correct any errors.
c. What is the first primary tooth to NOTE: If you make any errors, return to
erupt? Information section 18:1 to review the
material. Then correct your drawing.
d. State the age when permanent teeth
begin to erupt to replace the primary 8. Replace all equipment.
teeth. 9. Wash hands.
e. What is the first permanent tooth to
erupt?
f. What is the total number of primary
teeth? Of permanent teeth?
Practice
g. What does the term mixed dentition evaluation sheet for 18:1,
mean? At what ages does it usually Identifying the Structures and
occur? Tissues of a Tooth, to practice this
4. Use an anatomical model or chart of a procedure. When you believe you
tooth to identify and locate each of the have mastered this skill, sign the
following sections or divisions of a sheet and give it to your instructor
tooth: for further action
a. crown
b. root listed on the evaluation sheet, your
558 CHAPTER 18
To name the primary teeth, the mouth is

18:2 INFORMATION divided into quadrants or four sections: maxil-
lary right, maxillary left, mandibular right, and
Identifying the Teeth mandibular left. A transverse, or horizontal, plane
The four main types of teeth and their loca- separates the mouth into an upper, or maxillary,
tions and characteristics are: and lower, or mandibular, arch or jaw. Each tooth
is then labeled as either maxillary or mandibu-
♦ Incisors
lar. Teeth in the sockets, or alveoli, of the maxilla,
Located in the front and center of the mouth
or upper jawbone, are called maxillary. Teeth in
Broad, sharp edge
the alveoli of the mandible, or lower jawbone, are
Used to cut or bite food
called mandibular. A midsagittal plane, also called
Important for pronouncing Ss and Ts when
a median or midline plane, divides the mouth into
speaking
a right and left half. Each tooth is then identified
Central incisors are in the center
as right or left, depending on its location in the
Lateral incisors are on the sides of the centrals
mouth. In figure 18-3, positions of the teeth are
♦ Cuspids shown as though you were facing another person
Also called canines, or eyeteeth and looking into the mouth. This creates a mirror
Located at angles of lips image and right and left are reversed.
Used to tear food
Longest teeth in the mouth NOTE: Your left is the patient’s right; your right is
♦ Bicuspids the patient’s left.
Also called premolars
Located before the molars, from front to back Each primary tooth has a specific name. For
Not present in primary dentition example, the central incisor in the maxillary right
Used to pulverize or grind food quadrant or arch is called the maxillary right cen-
♦ Molars tral incisor. The central incisor in the maxillary left
Teeth in the back of the mouth quadrant is called the maxillary left central incisor.
Largest and strongest teeth The central incisor in the mandibular left quad-
Used to chew and grind food rant is called the mandibular left central incisor.
The central incisor in the mandibular right quad-
Primary, or deciduous, teeth: This is the rant is called the mandibular right central incisor.
first set of teeth. Although they are also called The same pattern applies to all of the lateral inci-
“baby” teeth, this is an inappropriate term sors, cuspids, 1st molars, and 2nd molars.
because it implies that the primary teeth have no
permanent value and are unimportant. In reality, Midsagittal Plane
they serve the important function of maintaining
Maxillary Right Maxillary Left
correct spacing for permanent teeth. There are 20
Central incisor Central incisor
primary teeth:
Lateral incisor Lateral incisor
Ten maxillary (upper):
Cuspid Cuspid
Two central incisors
Two lateral incisors 1st Molar 1st Molar
Transverse Plane
Two cuspids (canines) 2nd Molar 2nd Molar

Two 1st molars
Two 2nd molars 2nd Molar 2nd Molar
Ten mandibular (lower):
1st Molar 1st Molar
Two lateral incisors Cuspid Cuspid
Two cuspids (canines) Lateral incisor Lateral incisor
Two 1st molars
Two 2nd molars
Mandibular Right Mandibular Left
NOTE: There are no bicuspids in primary
dentition. FIGURE 18-3 Primary (deciduous) teeth.
Permanent, or succedaneous, teeth: This Sixteen maxillary (upper):

is the second set of teeth (figure 18-4). There are Two central incisors
32 permanent teeth: Two lateral incisors
Two cuspids (canines)
Midsagittal Plane
Two 1st bicuspids (premolars)
Maxillary Right Maxillary Left Two 2nd bicuspids (premolars)
Two 1st molars
Two 2nd molars
Two 3rd molars (wisdom teeth)
Cuspid Cuspid
Sixteen mandibular (lower):
1st Bicuspid 1st Bicuspid
2nd Bicuspid 2nd Bicuspid
Two lateral incisors
1st Molar 1st Molar
Two cuspids (canines)
Transverse Plane
2nd Molar 2nd Molar
Two 1st bicuspids (premolars)
3rd Molar 3rd Molar Two 2nd bicuspids (premolars)
Two 1st molars
Two 2nd molars
3rd Molar 3rd Molar Two 3rd molars (wisdom teeth)
2nd Molar 2nd Molar
NOTE: Each permanent tooth in figure 18-4
1st Molar 1st Molar
has its own name, depending on the quad-
2nd Bicuspid 2nd Bicuspid
rant it is in. Each is labeled as maxillary or
1st Bicuspid 1st Bicuspid
mandibular and right or left, following the
Cuspid Cuspid
same pattern used to name each primary
tooth.
Mandibular Right Mandibular Left STUDENT: Go to the workbook and complete
the assignment sheet for 18:2, Identifying the Teeth.
FIGURE 18-4 Permanent (succedaneous) teeth. Then return and continue with the procedure.
PROCEDURE 18:2
word maxillary on paper. Check for
Identifying the Teeth correct spelling.
b. Point to all of the lower teeth and
Equipment and Supplies state the name mandibular. Write
Model or unlabeled chart of primary or decid- the word mandibular on paper.
uous teeth, model or unlabeled chart of per- Check for correct spelling.
manent or succedaneous teeth, paper, and c. Imagine a line in the midsagittal
pen or pencil (median or midline) plane that
divides the mouth into right and left
Procedure sides. Point to all the teeth on the
right side of the mouth. Point to all
1. Assemble equipment. the teeth on the left side of the
2. Wash hands. mouth.
3. Use the model or unlabeled chart of pri- NOTE: Remember, you are on the
mary (deciduous) teeth to practice the outside of the mouth looking in.
following: Teeth on your right side are left teeth,
and teeth on your left side are right
a. Point to all of the upper teeth and teeth.
state the name maxillary. Write the
560 CHAPTER 18
PROCEDURE 18:2
d. Point to all four central incisors, lat- e. Name each tooth by its correct name.
eral incisors, cuspids, 1st molars, and For example, state maxillary right 3rd
2nd molars. State the names out molar, maxillary right 2nd molar, and
loud. continue until you have named all
the teeth.
e. Name each tooth by its correct name.
For example, say maxillary right cen- f. Number your paper from 1 to 32.
tral incisor, maxillary right lateral Write the names for all 32 permanent
incisor, and continue until you have teeth. Check the spelling of each
named all the teeth. name.
f. Number your paper from 1 to 20. 5. Replace all equipment.
Write the names for all 20 primary
6. Wash hands.
teeth. Check the spelling of each
name.
4. Use the model or unlabeled chart of the
permanent (succedaneous) teeth to
practice the following: Practice
a. Point to all the upper, or maxillary, Go to the workbook and use the
teeth. evaluation sheet for 18:2,
Identifying the Teeth, to practice this
b. Point to all the lower, or mandibular,
teeth.
c. Point to all the teeth on the right side sheet and give it to your instructor
of the mouth. Point to all the teeth on for further action.
the left side of the mouth.
d. Point to each of the central incisors,
lateral incisors, cuspids, 1st bicus- Final Checkpoint Using the criteria
pids, 2nd bicuspids, 1st molars, 2nd listed on the evaluation sheet, your
molars, and 3rd molars. instructor will grade your performance.
18:3 INFORMATION teeth. Each tooth has a number or letter by which

it is identified. It is much easier to call a perma-
Identifying Teeth Using the nent tooth number 8 rather than to call it the
maxillary right central incisor.
Universal/National Numbering The Universal/National Numbering System
System and the Federation for identifying primary, or deciduous, teeth is as
Dentaire International (FDI) follows:
System ♦ Teeth are identified by letters from A to T.
Several charting methods are used to identify the ♦ Labeling takes place in a circular pattern.
teeth. The most common method used in the
United States is the Universal/National Number- ♦ Starting at the maxillary right 2nd molar,
ing System. It was adopted by the American Den- which is A, and moving to the left side of the
tal Association in 1968 and is used on most dental maxillary arch, each tooth is assigned a differ-
insurance forms and dental charts. ent letter. The maxillary left 2nd molar is J.
The Universal/National Numbering Sys- ♦ Dropping down to the mandibular left 2nd
tem is an abbreviated form for identifying the molar, which is K, and moving from the left to
the mandibular right teeth, continue lettering the left to the mandibular right teeth, con-
each mandibular tooth. The mandibular right tinue numbering each tooth in the mandibu-
2nd molar is T. lar arch. The mandibular right 3rd molar is
♦ Figure 18-5 demonstrates how primary or number 32.
deciduous teeth are identified by the Univer- ♦ Figure 18-6 demonstrates how permanent
sal/National Numbering System. Remember, teeth are identified by the Universal/National
this is a mirror image. The teeth on your right Numbering System.
are the patient’s left teeth, and teeth on your
The Federation Dentaire International
left are the patient’s right teeth.
(FDI) System is another method for numbering
♦ In some areas, a lowercase d is used for pri- the teeth. It is used in some dental offices in the
mary or deciduous teeth. If this method is United States, and is the most widely used system
used, the maxillary right 2nd molar is d-1. in Canada and European countries. It uses a two-
Numbering continues across the maxillary digit code that identifies the quadrant and the
arch until the maxillary left 2nd molar is d-10. tooth. This makes it easy to use on a computer-
Dropping down to the mandibular arch, the ized system. The FDI system to identify primary
mandibular left 2nd molar is d-11. Numbering or deciduous teeth is as follows:
continues across the arch until the mandibu-
lar right 2nd molar is d-20.
♦ The mouth is divided into 4 quadrants.
♦ Code numbers are assigned to each quadrant:
The Universal/National Numbering System
maxillary right is 5, maxillary left is 6, man-
for identifying permanent, or succedaneous,
dibular left is 7, and mandibular right is 8.
teeth is as follows:
♦ Teeth in each quadrant are numbered from 1
♦ Teeth are identified by numbers from 1 to 32. to 5, starting with the central incisor and end-
♦ The mouth is encircled as each tooth is ing with the second molar.
labeled.
♦ Starting at the maxillary right 3rd molar, which
is 1, and moving around the arch to the left
side of the maxillary arch, each tooth is Maxillary Right Maxillary Left
assigned a number. The maxillary left 3rd
8 9
molar is number 16. 7 10
♦ Dropping down to the mandibular left 3rd 6 11
molar, which is number 17, and moving from 5 12
4 13
3 14
Maxillary RIght Maxillary Left
2 15
E F
D G
1 16
C H
B I 32 17
A J 31 18
30 19
T
K 29 20
S L 28 21
R M 27 22
Q N
26 25 24 23
P O

FIGURE 18-6 Coding by the Universal/National
FIGURE 18-5 Coding by the Universal/National Numbering System for permanent or succedaneous
Numbering System for primary or deciduous teeth. teeth.
562 CHAPTER 18
♦ The number of the quadrant is used first fol- Maxillary right 1 1 Maxillary left
lowed by the number of the tooth to code the quadrant quadrant
"1" "2"
tooth. For example, the maxillary right central
11 21
incisor is tooth number 51. The 5 represents 13 12
22
23
maxillary right and the 1 represents the cen-
14 24
tral incisor. 25
15
♦ Figure 18-7 demonstrates how primary teeth
16 26
are identified by the FDI System.
17 27
The FDI System to identify permanent or suc-
cedaneous teeth is as follows: 8 18 28 8
♦ The mouth is divided into 4 quadrants.

3RD MOLARS
♦ Code numbers are assigned to each quadrant: 48 38
maxillary right is 1, maxillary left is 2, man- 8 8
dibular left is 3, and mandibular right is 4. 47 37
♦ Teeth in each quadrant are numbered from 1
to 8, starting with the central incisor and end- 46 36
ing with the third molar. 45 35
♦ The number of the quadrant is used first fol- 44 34
lowed by the number of the tooth to code the 43 33
42 41 31 32
tooth. For example, the mandibular left lateral
incisor is tooth number 32. The 3 represents
mandibular left and the 2 represents lateral 1 1
Mandibular right Mandibular left
incisor. quadrant quadrant
Permanent teeth
♦ Figure 18-8 demonstrates how permanent "4" "3"
teeth are identified by the FDI System. FIGURE 18-8 The Federation Dentaire Interna-
tional (FDI) System of coding for permanent or
succedaneous teeth.
Maxillary right 1 1 Maxillary left

The FDI System can also be used to describe the
quadrant quadrant oral cavity and/or the maxillary or mandibular
"5" "6" arches:
52 51 61 62
53 63 ♦ 00 refers to the entire oral cavity; for example:
54 64 panoramic X-ray 00
65
♦ 01 refers to the entire maxillary arch; for exam-
5 55 5 ple: fluoride treatment 01
♦ 02 refers to the entire mandibular arch; for
2ND MOLARS example: denture 02
5 5
85 75 Dental assistants must use the method of
74 numbering the dentist prefers. It is important to
84
become familiar with the various systems to assist
83 73
82 81
with charting conditions and completing insur-
71 72
ance forms.
Mandibular right
quadrant
1 1 Mandibular left
quadrant
Primary teeth the assignment sheet for 18:3, Identifying Teeth
"8" "7"
FIGURE 18-7 The Federation Dentaire Interna- Using the Universal/National Numbering System
tional (FDI) System of coding for primary or decidu- and Federation Dentaire International System.
ous teeth. Then return and continue with the procedure.
PROCEDURE 18:3A
4. Use the model or chart of permanent or
Identifying Teeth succedaneous teeth to practice the fol-
Using the Universal/ lowing:
National Numbering a. Draw a sketch of the 32 permanent

teeth. Label each tooth in your sketch
System using the numbers of the Universal/
National Numbering System. Start by
Equipment and Supplies labeling the maxillary right 3rd molar
as number 1. Continue labeling all
Model or chart of primary or deciduous teeth, maxillary teeth from 1 to 16, moving
model or chart of permanent or succedane- from the maxillary right teeth to the
ous teeth, paper, and pen or pencil maxillary left teeth. Then, label the
mandibular teeth from 17 to 32, mov-
Procedure ing from the mandibular left teeth to
the mandibular right teeth.
b. Look at the model or chart of perma-
2. Wash hands.
nent teeth. Name teeth at random
3. Use the model or chart of primary or using the full names, such as man-
deciduous teeth to practice the fol- dibular left 2nd molar. Then, deter-
lowing: mine the correct number for each
a. Draw a sketch of the 20 primary teeth. tooth. In the previous example, the
Label each tooth in your sketch using number would be 18. Refer to your
the letters of the Universal/National sketch as needed.
Numbering System. Start by labeling c. Call out numbers from 1 to 32 at ran-
the maxillary right 2nd molar as A. dom. Name the tooth that corre-
Continue labeling all maxillary teeth sponds with each number.
from A to J, moving from the maxil-
lary right teeth to the maxillary left d. Repeat the previous two steps until
teeth. Then, label the mandibular you feel confident about using the
teeth from K to T, moving from the Universal/National Numbering Sys-
mandibular left teeth to the mandib- tem to identify permanent teeth.
ular right teeth. 5. Replace all equipment.
b. Look at the model or chart of primary 6. Wash hands.
teeth. Name teeth at random using
the full names, such as maxillary
right central incisor. Then, determine
the correct letter for each tooth. In
the previous example, the letter Practice
would be E. Refer to your sketch as Go to the workbook and use the
needed. evaluation sheet for 18:3A,
c. Call out letters from A to T at random. Identifying Teeth Using the
Name the tooth that corresponds Universal/National Numbering
with each letter. System, to practice this procedure.
d. Repeat the previous two steps until mastered this skill, sign the sheet
you feel confident about using the
Universal/National Numbering Sys-
further action.
tem to identify primary teeth.
e. Repeat naming each primary or
deciduous tooth but use the letter d Final Checkpoint Using the criteria
with a number from 1 to 20 to iden- listed on the evaluation sheet, your
tify the teeth. instructor will grade your performance.
564 CHAPTER 18
PROCEDURE 18:3B
e. Call out number codes at random.
Identifying Teeth Name the tooth that corresponds
Using the Federation with each number.
Dentaire International f. Repeat the previous two steps until

you feel confident about using the
(FDI) Numbering FDI System to identify primary
System teeth.
4. Use the model or chart of permanent or
Equipment and Supplies succedaneous teeth to practice the fol-
lowing:
Model or chart of primary teeth, model or
chart of permanent teeth, paper, and pen or a. Draw a sketch of the 32 permanent
pencil teeth. Divide the mouth into four
quadrants. Draw a transverse line to
separate the teeth into maxillary or
Procedure upper and mandibular or lower teeth.
1. Assemble equipment. Draw a midsagittal line to separate
2. Wash hands. the mouth into right and left sides.
3. Use the model or chart of primary or b. Label the maxillary right quadrant as
deciduous teeth to practice the follow- 1, the maxillary left quadrant as 2, the
ing: mandibular left quadrant as 3, and
a. Draw a sketch of the 20 primary teeth. the mandibular right quadrant as 4.
Divide the mouth into four quad- c. Label the teeth in each quadrant from
rants. Draw a transverse line to sepa- 1 to 8. Begin with the central incisor
rate the teeth into maxillary or upper as 1, and end with the third molar
and mandibular or lower teeth. Draw as 8.
a midsagittal line to separate the
mouth into right and left sides. d. Examine the model of permanent
teeth. Name teeth at random using
b. Label the maxillary right quadrant as
correct names, such as mandibular
5, the maxillary left quadrant as 6, the
left first bicuspid. Then, combine the
mandibular left quadrant as 7, and
number of the quadrant with the
the mandibular right quadrant as 8.
number of the tooth to determine
c. Label the teeth in each quadrant the correct code for the tooth. In the
from 1 to 5. Begin with the central previous example, the correct code
incisor as 1, and end with the second for the tooth is number 34. The 3 rep-
molar as 5. resents mandibular left and the 4
d. Examine the model of primary teeth. represents first bicuspid.
Name teeth at random using correct
names, such as maxillary left central e. Call out number codes at random.
incisor. Then, combine the number Name the tooth that corresponds
of the quadrant with the number of with each number.
the tooth to determine the correct f. Repeat the previous two steps until
code for the tooth. In the previous you feel confident about using the
example, the correct code for the FDI System to identify permanent
tooth is number 61. The 6 represents teeth.
maxillary left, and the 1 represents
central incisor.
PROCEDURE 18:3B
6. Wash hands.
Practice
Identifying Teeth Using the
Federation Dentaire International
(FDI) System, to practice this
Final Checkpoint Using the criteria sheet and give it to your instructor
listed on the evaluation sheet, your for further action.
♦ Anterior means “toward the front.” The cen-

18:4 INFORMATION tral and lateral incisors and cuspids are ante-
Identifying the Surfaces rior teeth.
of the Teeth ♦ Posterior means “toward the back.” The
bicuspids and molars are posterior teeth.
To chart conditions of the teeth, the dental
assistant must be familiar with the crown Each tooth then is divided into two main sec-
surfaces of the teeth. tions: the crown and the root. The crown is the
The first step is to differentiate between ante- part that is visible in the mouth, or oral cavity.
rior and posterior teeth (figure 18-9). The root is the section that is located below the
gingiva, or gums. The crown is divided into five
sections, or surfaces.
Crown surfaces of the anterior teeth (figure
18-10) are as follows:
Anterior
Root
Midline of mouth
Midline of
mouth
Posterior Posterior
Mesial
Distal Crown
Labial
Incisal
Anterior
FIGURE 18-10 Crown surfaces on an anterior
tooth. The lingual (tongue) surface is not seen on
FIGURE 18-9 Anterior and posterior teeth. this diagram.
566 CHAPTER 18
♦ Labial: crown surface next to the lips; facial bining the names of the surfaces involved. Use the
surface following guidelines when naming line angles:
♦ Lingual: crown surface next to the tongue ♦ Drop the suffix -al of the first word and replace
♦ Incisal: cutting or biting edge of the tooth it with o.
♦ Mesial: side surface closest to or facing toward ♦ Whenever mesial or distal surfaces are
the midline (the imaginary line dividing mouth involved, use mesial or distal as the first part
into a right half and a left half) of the word. For example, a line angle formed
♦ Distal: side surface away from the midline by the mesial and labial surfaces would be
(that is, the side surface facing toward the called a mesiolabial line angle.
back of the mouth) ♦ Use incisal or occlusal as the last part of the
word. For example, a line angle formed by the
Crown surfaces of the posterior teeth (figure
lingual and occlusal surfaces would be called
18-11) are as follows:
a linguoocclusal line angle.
♦ Buccal: crown surface next to face or cheek;
Point angles form where three crown sur-
facial surface
faces meet. The name of each point angle is
♦ Lingual: crown surface next to the tongue formed by combining the names of the surfaces
♦ Occlusal: chewing or grinding surface of the involved. Use the following guidelines when
tooth naming point angles:
♦ Mesial: side surface toward the midline of the ♦ Drop the suffix -al of the first two words and
mouth replace with o.
♦ Distal: side surface away from the midline of ♦ Use mesial or distal as the first part of the
the mouth word. For example, a point angle formed by
Abbreviations used for the crown surfaces the distal, labial, and incisal surfaces would be
will depend on the doctor’s preference. However, called a distolabioincisal point angle.
some commonly used abbreviations for the ♦ Use incisal or occlusal as the last part of the
crown surfaces include: word. For example, a point angle formed by
Mesial M the mesial, lingual, and occlusal surfaces would
Distal D be called a mesiolinguoocclusal point angle.
Labial La An anterior tooth has eight line angles and
Lingual L or Li or Lin four point angles. The names of the angles and
Incisal I suggested list of abbreviations include:
Occlusal O
Buccal B Line Angles of Anterior Teeth
Linguoincisal LiI
Line angles form where two crown surfaces Labioincisal LaI
meet. The name of each angle is formed by com- Mesiolabial MLa
Mesioincisal MI
Mesiolingual MLi
Distolingual DLi
Midline of mouth
Root Distoincisal DI
Distolabial DLa
Mesial Point Angles of Anterior Teeth

Buccal Mesiolinguoincisal MLiI
Crown
Mesiolabioincisal MLaI
Distolabioincisal DLaI
Distolinguoincisal DLiI
Distal Occlusal
FIGURE 18-11 Crown surfaces on a posterior A posterior tooth has eight line angles and
tooth. The lingual (tongue) surface is not seen on four point angles. The names of the angles and
this diagram. suggested list of abbreviations include:
Line Angles of Posterior Teeth Point Angles of Posterior Teeth

Mesioocclusal MO Mesiolinguoocclusal MLiO
Mesiolingual MLi Mesiobuccoocclusal MBO
Mesiobuccal MB Distobuccoocclusal DBO
Distoocclusal DO Distolinguoocclusal DLiO
Distolingual DLi
Distobuccal DB STUDENT: Go to the workbook and complete
Linguoocclusal LiO the assignment sheet for 18:4, Identifying the Sur-
Buccoocclusal BO faces of the Teeth. Then return and continue with
the procedure.
PROCEDURE 18:4
Remember, a line angle forms where
Identifying the two crown surfaces meet. There are a
Surfaces of the Teeth total of eight line angles.
8. Locate the line angles on the posterior
Equipment and Supplies teeth. Write the correct names on paper.
There are a total of eight line angles.
Model of the teeth, paper, pen or pencil
9. Locate the point angles on the anterior
Procedure teeth. Write the correct names on the
paper. Remember, a point angle forms
1. Assemble equipment. where three crown surfaces meet. There
are a total of four point angles.
2. Wash hands.
10. Locate the point angles on the posterior
3. Use the model of the teeth to point out
teeth. Write the correct names on the
and identify the teeth and surfaces.
paper. There are a total of four point
4. Identify the anterior teeth. Identify the angles.
posterior teeth.
11. Practice steps 4–10 until you feel confi-
5. Locate the following crown surfaces on dent about identifying the surfaces on
the anterior teeth: the teeth.
a. labial 12. Replace all equipment.
b. incisal edge 13. Wash hands.
c. lingual
d. mesial (draw an imaginary line to
separate the mouth into a right and
left side) Practice
e. distal Go to the workbook and use the
6. Locate the following crown surfaces on evaluation sheet for 18:4,
the posterior teeth: Identifying the Surfaces of the Teeth,
a. buccal to practice this procedure. When you
b. occlusal
c. lingual instructor for further action.
d. mesial
e. distal
7. Locate the line angles on the anterior listed on the evaluation sheet, your
teeth. Write the correct names on paper. instructor will grade your performance.
568 CHAPTER 18
allergies, and other pertinent medical infor-

18:5 INFORMATION mation (Chapter 23:4 in this textbook dis-
cusses a medical history in detail.)
Charting Conditions of the Teeth
♦ Charting area: anatomic or geometric dia-
A dental assistant may be required to chart con- grams of the teeth
ditions of the teeth on dental charts or insurance
forms. Forms, symbols, and abbreviations vary ♦ Treatment section: written record of treatment,
from office to office. services performed, and in some cases, fees
Dental charts are legal records. They must be and amounts paid
complete, neat, and correct. Information must be ♦ Radiographic history: record of date and type
current and should be updated each time a of dental radiographs or X-rays
patient visits the office. The dental charts must ♦ Remarks: area for written notations by dentist
be stored in a locked file cabinet to maintain con- or dental hygienist
fidentiality and to prevent loss. A dental chart
may contain the following sections: In figure 18-12A, permanent, or succedane-
ous, teeth are represented by the anatomic dia-
♦ Personal patient information: full name of grams. The teeth are numbered according to the
patient, birthdate or age, address, telephone Universal/National Numbering System. Maxillary
number, place of employment, physician’s teeth are above the transverse line, and mandibu-
name and address, and insurance informa- lar teeth are below the line. In figure 18-12B, both
tion primary and permanent teeth are represented by
♦ Medical history: diseases or medical condi- the geometric diagrams. Primary teeth are labeled
tions patient has, special medical precautions, with letters according to the Universal/National
MAXILLARY
LINGUAL
RIGHT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 LEFT
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
LINGUAL
MANDIBULAR
FIGURE 18-12A A sample anatomic diagram dental chart of permanent dentition with different crown
surfaces shaded.
POSTERIOR ANTERIOR POSTERIOR
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
MAXILLARY
A B C D E F G H I J
LINGUAL PRIMARY
LEFT
TEETH
RIGHT
T S R Q P O N M L K
PERMANENT TEETH
MANDIBULAR
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

FIGURE 18-12B A sample geometric diagram dental chart with different crown surfaces shaded on permanent dentition.
Dental Assistant Skills
569
570 CHAPTER 18
Numbering System. Permanent teeth are labeled to ask questions about which surfaces are repre-
with numbers. sented by different diagrams.
Surfaces of the teeth are also shown in figures
18-12A and 18-12B. The surfaces have been Notation methods for dental charting vary. In
shaded to help familiarize you with chart repre- some dental offices, a pencil is used so that if
sentations. Note the examples for the following errors occur, they can be erased. In other offices,
surfaces, the numbers of which refer to the a pencil is initially used but charting is completed
Universal/National Numbering System: in ink. In most offices, colored pencils are used.
Red indicates carious lesions (decay) or treat-
♦ Occlusal: numbers 1 and 32 ment needed. Blue indicates treatment com-
♦ Incisal: numbers 8 and 25 pleted, such as restorations or crowns. Check
with the doctor to determine which system is
♦ Buccal: numbers 3 and 30
used and learn this system. Never hesitate to ask
♦ Labial: numbers 9 and 24 questions while you learn the preferred method.
♦ Lingual: numbers 5, 10, 23, and 28 Symbols used for anatomic diagrams can also
vary. Again, check with the doctor to determine
♦ Mesial: numbers 6 and 27; not actually shown which symbols you should use.
on the anatomic diagram but noted along the Samples of symbols are shown on figures
mesial edges of other surfaces 18-13A and 18-13B. The numbers used in this fig-
♦ Distal: numbers 12 and 21; not actually shown ure refer to the Universal/National Numbering
on the anatomic diagram but noted along the System:
distal edges of other surfaces 䊊 Carious lesion (decay): Circle or outline any
area involving a carious lesion or decay. In figures
NOTE: Figures 18-12A and 18-12B are sample 18-13A and 18-13B, carious lesions are shown on
charts. Dental charts vary slightly. Never hesitate the following teeth and surfaces:
MAXILLARY
LINGUAL
RIGHT
LEFT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
MANDIBULAR
RCT
FIGURE 18-13A An anatomic diagram of permanent dentition with conditions noted by symbols.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
MAXILLARY
A B C D E F G H I J
LINGUAL
LEFT
RIGHT
T S R Q P O N M L K
MANDIBULAR
RCT
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

FIGURE 18-13B A geometric diagram with conditions noted by symbols on permanent dentition.
Dental Assistant Skills
571
572 CHAPTER 18
1 occlusal 6 distal ♦ Information must be neat, correct, and com-

2 distoocclusal 7 incisal plete.
3 mesioocclusodistal 8 lingual
4 buccal 9 labial
♦ Abbreviations are used to denote teeth, sur-
faces, treatment completed, and base
5 lingual 10 mesiolingual
cements.
䊉 Amalgam restoration: Use a circle filled in
solid to indicate amalgam restoration (number ♦ Information recorded usually includes date,
12, occlusal amalgam restoration) numbers of teeth treated, and services per-
䉺 Esthetic or composite restoration: Use a circle formed (for example, examination, radio-
with dot in the middle to indicate esthetic resto- graphs, restorations, crowns, impressions).
ration such as composite or silicates (number 11, ♦ If treatment was not done to a particular tooth
composite on labial surface) (for example, only full-mouth radiographs and
X Missing tooth: Draw an X over the entire dia- examination were performed), the number
gram of a missing tooth (number 13) column should be left blank for the Universal/
/ Tooth needs extraction: Draw one line through National numbering system. If the FDI system
the entire diagram of a tooth to be extracted is used, the code 00 for the entire oral cavity,
(number 14) 01 for the entire maxillary arch, and 02 for the
// Extracted tooth: Draw two lines through the entire mandibular arch is entered on the
entire diagram of a tooth that has been extracted chart.
(number 15); some offices use an X in place of the
two lines. Common abbreviations used for services ren-
䊊 Impacted tooth: Circle the entire diagram of dered are as follows:
an impacted tooth (tooth that is unable to erupt NOTE: This list varies from area to area. Use the
into its proper position) (number 16) abbreviations your doctor prefers.
AM or Amal.: amalgam restoration, silver
RCT Needs endodontic treatment: Write filling
or under a tooth that needs endodontic Anes: anesthetic
ENDO (root canal) treatment (number 17) BWXR: bite-wing X-rays
Com or Ant: composite restoration, anterior
❘ Endodontic treatment: Draw a heavy line in restoration, or esthetic restoration
the pulp canal of a tooth with completed end- Cr or CR: crown; type may be included (FGCr
odontic (root canal) treatment (number 20) for full gold crown, PFMCr for porcelain fused to
Fractured tooth: Draw a saw line in the metal crown, and PJCr for porcelain jacket
affected area of a fractured tooth (number 24) crown)
䊊 Porcelain or esthetic crown: Circle entire Ex. or Clin. Ex.: examination or clinical exam-
crown for a porcelain or esthetic crown (number ination
25) Ext.: extraction
䊠 Gold crown: Circle the entire crown and fill in FMXR: full-mouth series of X-rays
with lines for a gold crown (number 29) Imp.: impression; type may be included (Alg
NOTE: Remember, these are only one group of for alginate, RB for rubber base)
symbols. Many other symbols are in use. Learn Pro or Prophy: prophylaxis, cleaning teeth
the symbols you are required to use. RCT or Endo: root canal, or endodontic,
In addition to using symbols in the anatomic treatment
diagram, all treatments or services rendered to Check your understanding of what treatment
the patient are also recorded on the dental chart. was completed in the following examples of
The following points should be noted: charting by referring to the previous list of abbre-
viations.
2/10/— Ex., Pro, FMXR
♦ Only services performed are recorded in this 3/1/— 30 AM to MOD, Anes
section. Treatment performed by a previous 5/6/— 8 Ant to MLa
dentist, the presence of carious lesions, or Some dental offices are using computerized
missing teeth are not noted here. dental charting in place of manual charting.
♦ Information must be recorded in ink. Some software is voice activated and totally auto-
matic. Other software requires the use of a computer, keyboard, and/or light pen must be
keyboard or light pen to input the information. covered with protective barriers so they are not
The software program places the correct symbol contaminated with the spray of saliva and body
on the surface(s) indicated. Most software also fluids during a dental procedure. The barriers
color codes the notation when the doctor or must be changed between patients to prevent
assistant indicate whether the notation “needs cross-contamination.
treatment” or “treatment is complete.” Dental
charting software is easy to use once an individ- STUDENT: Read Procedure 18:5, Charting
ual becomes familiar with how it operates. How- Conditions of the Teeth. Then go to the workbook
ever, the user must still know how to indicate and complete assignment sheet 18:5, Charting
tooth surface or work performed. In addition, the Conditions of the Teeth.
PROCEDURE 18:5
7. On the anatomic diagrams of the teeth
Charting Conditions and in the services rendered area, chart
of the Teeth all treatment completed. Use appropri-
ate abbreviations for treatment com-
Equipment and Supplies pleted. Refer to Information section 18:5
to determine common abbreviations
Dental cards or charts; charting assignments; for services rendered.
pen, pencil, or colored pencils
8. Double-check all notations on the chart
for accuracy. Make sure all notations are
Procedure neat and legible.
1. Assemble equipment. 9. When you have completed Charting
Assignment 1, give it to your instructor.
2. Wash hands.
Your instructor will grade the assign-
3. Use the dental card or chart to complete ment according to the criteria listed on
Charting Assignment 1. the evaluation sheet.
4. Use a pen, pencil, or colored pencils to 10. Note all corrections on your graded
complete all information. Your instruc- assignment. Question your instructor if
tor will specify which to use. you do not understand the corrections.
5. Fill in the patient information area with Then, complete Assignment 2 and give
name, address, and telephone number. it to your instructor. Repeat the entire
You may place your name, address, and process for Assignment 3.
telephone number on the practice 11. Replace all equipment.
chart.
12. Wash hands.
6. Chart each condition noted on the
assignment. Check to be sure you are Final Checkpoint Using the criteria
using the correct anatomic diagram. listed on the evaluation sheet, your
Refer to Information section 18:5 to instructor will grade the three charting
determine correct symbols. assignments.
574 CHAPTER 18
mask, gloves, and a gown or special clothing. The

18:6 INFORMATION masks and gloves are disposable and are discarded
after interaction with each patient. Protective eye-
Operating and Maintaining wear should be cleaned and disinfected between
Dental Equipment patients. Some dental offices use disposable
Correct use and maintenance of dental equip- gowns that are impermeable to fluids. The gowns
ment may be one of the responsibilities of the are discarded after each patient. Other dental
dental assistant. Remember always to check the offices use special uniforms, laboratory coats, or
manufacturer’s recommendations prior to using jackets. This type of protective clothing may not
or maintaining any equipment. This section probe worn outside the dental office. The Occupa-
vides some basic facts about the various pieces of tional Safety and Health Administration (OSHA)
dental equipment. Note that the equipment dis- requires doctors to provide protective clothing
cussed is used for four-handed dentistry. The that is laundered in the office or by a commercial
term four-handed dentistry describes the dentist laundry service. All office personnel assisting with
and dental assistant working together as a team dental procedures change into the protective
while seated on either side of a patient who is clothing when they arrive at work. If they leave
lying in a supine position in the dental chair. the office for any reason, they must remove the
Infection control is essential while operating protective clothing and dress in their own clothes.
and maintaining any piece of dental equip- When the protective clothing is removed, it must
ment. During dental procedures, equipment can be folded inward to keep contaminated areas on
be contaminated with blood, saliva, and body flu- the inside. In addition, the clothing must be
ids. Standard precautions, described in Chapter changed at least daily or immediately if it has been
14:4, must be observed at all times. All personnel splashed with body fluids. These regulations were
performing or assisting with any dental procedure established by OSHA to protect dental personnel,
must wear personal protective equipment (PPE) their families, and the public from exposure to
(figure 18-14). This includes protective eyewear, a clothing that has been contaminated by the mist
of body fluids that is expelled during every dental
procedure.
Standard precautions must also be followed
while using any dental instruments, equipment,
or supplies. Protective barriers must be placed on
many parts of the equipment prior to use (figure
18-15). Special covers can be purchased for the
FIGURE 18-14 All personnel performing or FIGURE 18-15 Protective barriers, such as
assisting with any dental procedure must wear plastic wrap or commercial covers, must be placed
personal protective equipment (PPE). on many parts of the dental equipment prior to use.
dental chair, handles and switches on the dental

light, handpieces, air–water syringe, high-volume
evacuator, tubing, and the X-ray tube head. Plas-
tic wrap or aluminum foil can also be used to
cover surfaces such as the handles and switches
on the dental light. Clear plastic wrap can be used
on the X-ray tube head. Plastic-backed paper or
plastic wrap can be used on the headrest, arm-
rest, and other parts of the dental chair, and to
cover the tops of the dental carts. Some offices
use clear plastic dry-cleaning bags to cover the
dental chair. After the procedure is complete, the
bag is removed from the chair, turned inside out, A
and used as a trash bag for the other barriers (fig-
ure 18-16).
After any dental procedure, standard precau-
tions must be followed to clean and disinfect or
sterilize any contaminated equipment. The assis-
tant must wear gloves to remove the contami-
nated barriers. The areas must then be disinfected.
All surfaces are sprayed with a disinfectant and
wiped to remove any particles or debris. The areas
are then sprayed a second time, and the solution
is left in place for the period of time recom-
mended by the manufacturer, usually 10 minutes
(figure 18-17A and B). All surfaces are then wiped
again, and the contaminated gloves removed. B
After the hands are washed thoroughly, clean FIGURE 18-17 After a dental procedure is
protective barriers must be put in place before complete, contaminated surfaces are (A) sprayed
with a disinfectant and then (B) wiped and sprayed
the next dental procedure. By observing standard
a second time with a disinfectant.
precautions and proper disinfection/sterilization
procedures, the transmission of disease by dental
equipment can be prevented. chair. The light is used to illuminate the oral cav-
Most dental lights are mounted on the ceil- ity, or mouth, while the doctor works. The light is
ing of the dental unit or attached to the dental positioned 30–50 inches from the oral cavity. Both
the doctor and assistant should be able to adjust
the position of the light. Most lights contain dim-
mer switches to adjust the intensity of the light.
Prior to a procedure, protective barriers such as
plastic wrap, aluminum foil, or commercial cov-
ers are placed on the handles and switches of the
light. These must be removed and replaced with
clean barriers after each patient. In addition, all
parts that are touched must be disinfected after
each patient. Most manufacturers recommend
the use of a mild detergent and a soft cloth to
clean the light shield. The soft cloth prevents the
formation of scratches on the light shield. At least
once a week, all moving parts on the light should
FIGURE 18-16 After a dental procedure is be lubricated with a general, all-purpose oil.
complete, the plastic bag used to cover the chair The dental chair (figure 18-18) is designed
can be turned inside out and used as a trash bag for to position the patient comfortably while provid-
the other barriers. ing the doctor and the dental assistant with easy
576 CHAPTER 18
required time, and wiped again. The headrest

and/or the top of the chair is usually covered with
a plastic disposable cover, which is discarded and
replaced with a clean one after each patient. Most
manufacturers recommend frequent, thorough
cleaning with special upholstery cleaners or mild
soap solutions.
The air compressor provides air pressure
to operate the handpieces and air syringes on the
dental units. It is usually located in a storage area
or basement, and air lines are installed to carry
the air pressure to the dental units. The compres-
sor is usually set to provide 100 pounds of pres-
sure. The pressure gauge on the air compressor
should be checked frequently. If pressure goes
above 120 pounds, the doctor should be notified.
Careful maintenance of the air compressor is
essential.
Manufacturer’s recommendations must be
read and followed. Most air compressors are
sealed units and require no lubrication. In units
that require oil to operate, the oil level should be
checked frequently, usually weekly. These air
compressors have oil reservoirs covered by a cap
or plug. The cap or plug is removed to check the
FIGURE 18-18 The dental chair allows the oil level. If the oil level is low, the doctor should
patient to be positioned comfortably while providing be notified immediately. In addition, water from
the doctor and the dental assistant easy access to the compression of moist air accumulates in the
the oral cavity. main tank of the compressor. Most compressors
have automatic drain valves that open to release
the water when the water reaches a preset level. If
access to the oral cavity. Most chairs have thin, the compressor does not have an automatic drain
narrow headrests so the doctor and the dental valve, the water should be drained daily. The pres-
assistant can position themselves close to the sure must be at zero before the drain faucet or
patient. The chair reclines to place the patient in valve is opened to release the accumulated water.
a supine, or lying down, position. Most chairs Most air compressors contain special drain fau-
contain controls on both sides and/or on the cets on their tanks.
floor so they can be operated by the doctor or the The oral-evacuation system, also called a
dental assistant. The control to raise and lower central vacuum system, uses water to provide the
the height of the chair is usually located on the dental units with a suction action. It aids in
chair base and is operated by foot. The control to removing particles, debris, and liquids from the
recline or raise the chair is usually located on the oral cavity. Its action is similar to that of a vacuum
side of the chair and near the headrest; it is oper- cleaner. The system consists of a main pump with
ated by hand. Some chairs have foot controls to vacuum lines to the dental unit and is usually
raise or lower the chair because this eliminates located in a storage area or utility closet. Electri-
the need for protective barriers. Chairs also have cal control switches to turn the pump on and off
foot controls to lock the chairs in position. This are usually located on or near the dental unit.
prevents movement of the chair while the patient Wastes and liquids drawn into the system are dis-
is getting in or out of it. Cleaning the chair charged into a sanitary sewer line. A solids collec-
between patients is mandatory for infection con- tor trap is located on the oral evacuation unit or
trol. The headrest, armrest, and any other con- in the dental unit. This trap catches large parti-
taminated area must be wiped clean with a cles and must be cleaned daily. The particles
disinfectant, then resprayed, left in place for the should be emptied into a paper towel and placed
in the correct waste container. The trap should

be washed with a mild detergent, rinsed thor-
oughly, and dried. Some manufacturers recom-
mend using a germicide spray or liquid daily to
prevent the growth of organisms and the devel-
opment of unpleasant odors. Again, it is impor-
tant to read and follow the manufacturer’s
instructions on specific care and maintenance of
the oral-evacuation system.
Assistant’s carts vary from office to office,
but most carts contain the same basic equipment
FIGURE 18-20 An air–water, or tri-flow, syringe.
(figure 18-19). Drawers or areas for instrument
storage are found on some carts. Other carts have fluids from the mouth. Most ejectors contain
sliding tops with storage areas under the tops. In screw-type knobs that are used to turn the
addition, the following equipment is usually suction on and off. The tips are disposable
located on the cart: (figure 18-21). They must be changed after
♦ Tri-flow, or air–water, syringe: This is also each patient. The tip holder is covered with a
called a three-way syringe (figure 18-20). It protective barrier during use. The barrier is
provides air, water, or a combination of air removed after each patient, the holder and
and water for various dental procedures. Pro- tubing are disinfected, and a new barrier is
tective barrier covers are placed on the syringe put in place. At least once daily, the inside of
handle and tubing prior to each patient exam- the tip holder must be cleaned thoroughly
ination. After each use, the air-water syringe with a brush. A germicide solution or spray
should be run for at least 30 seconds to flush can also be used to clean the inside of the tip
out the unit. Plastic disposable tips are used in holder. The tubing can be sanitized by turning
some offices. Other offices use a metal tip that the saliva ejector on and drawing a disinfect-
is removable for sterilization in an autoclave. ing and deodorizing solution into it.
It must be changed and replaced with a sterile ♦ High-velocity oral evacuator (HVE): This is
tip after each patient. The syringe and tubing also called a high-volume or high-vacuum
must be wiped with a disinfectant after each evacuator (figure 18-22). It is used to remove
patient.
♦ Saliva ejector: This provides constant, low-
volume suction to remove saliva and other
FIGURE 18-21 A saliva ejector with a disposable

tip in position.
FIGURE 18-22 A high-velocity oral evacuator

FIGURE 18-19 A sample assistant’s cart. (Cour- removes particles, debris, and large amounts of
tesy of A-dec, Inc., Newberg, OR) liquid from the oral cavity.
578 CHAPTER 18
particles, debris, and large amounts of liquid

from the oral cavity. Various tips can be used in
the evacuator. Plastic disposable tips are dis-
carded. Metal tips and nondisposable, heavy
plastic tips are cleaned and sterilized in an
autoclave. The evacuator holder is covered with
a protective barrier during the procedure. The
barrier is removed after each patient, the holder
and tubing are disinfected, and a new barrier is
put in place. A disinfecting and deodorizing
solution can be suctioned into the tubing to
sanitize the interior of the unit. Most units con-
tain filter screens to trap larger particles drawn
into the evacuator. These screens must be
changed or emptied and cleaned daily. In addi-
tion, a slide valve is usually attached to the unit.
This is used to turn the unit on and off with FIGURE 18-23 A sample doctor’s cart. (Courtesy
ease. The valve should be removed daily for of A-dec, Inc., Newberg, OR)
thorough cleaning. It should be lubricated with
a silicone-type lubricant to prevent sticking. dental caries (decay) removal and fine-finish-
CAUTION: Because of possible contamina- ing work. The lower speed of this handpiece
tion from saliva, blood, or body fluids, stan- allows the doctor maximum control. Different
dard precautions must be observed while attachments can be used on this handpiece.
operating the saliva ejector and/or the oral- Two of the most common are the contra angle
evacuation systems. Gloves, masks, and protec- and the prophylaxis angle.
tive eyewear must be worn at all times. Gloves (1) Contra angle: This is used for cutting
and masks are discarded after each patient. In and polishing during various dental pro-
addition, masks must be changed any time they cedures (figure 18-24). Instruments called
become wet or are worn for longer than 30 min- burs are inserted into the contra angle.
utes. Protective eyewear must be disinfected, Burs are rotary instruments used to cut,
rinsed to remove the disinfectant, and dried shape, finish, and polish teeth, restora-
before being used for another patient. tions, and dental appliances. Burs have
three parts: the head or cutting portion,
♦ Cuspidor: This is a bowl or cup that can be the shank or part inserted in the hand-
used to allow the patient to expectorate (spit piece, and the neck, which joins the head
out) particles and water. Some cuspidors are to the shank. Some contra angles use
installed on dental units; others are portable latch-type burs, which contain a groove at
units. Most cuspidors are automatically the shank. Others use friction-grip, or FG,
flushed with running water. After each patient, burs, which have a smooth shank. Friction-
the cuspidor must be cleaned and disinfected. grip burs are held in place by a friction
Portable units are frequently sterilized.
Style and type of doctors’ carts also vary

from office to office (figure 18-23). Many contain
air–water syringes in addition to a variety of
handpieces. Most carts also have rheostats, or
foot controls used to operate the handpieces.
Basic handpieces found on a doctor’s cart include
the air–water syringe, high-velocity oral evacua-
tor (HVE), and/or saliva ejector. Two other hand-
pieces are as follows:
FIGURE 18-24 A low-speed handpiece with a
♦ Low-speed handpiece: This is also called a contra-angle attachment (top) and a prophylaxis-
conventional-speed handpiece. It is used for angle attachment (bottom).
chuck in the head of the contra angle (fig- water-cooled with a fine mist of water when it
ure 18-25). is used. An HVE or saliva ejector is used to suc-
(2) Prophylaxis angle: This attachment tion the water that accumulates in the patient’s
holds polishing cups, disks, and brushes mouth.
that are used to clean the teeth or to polish
After each patient, handpieces must be
restorations (refer to figure 18-24).
scrubbed thoroughly to remove debris, rinsed,
♦ High-speed handpiece: This is sometimes dried, and sterilized. If a handpiece cannot be
called an ultraspeed handpiece (figure 18-26). sterilized according to manufacturer’s instruc-
It is used to do most of the cutting and prepa- tions, it must be flushed with water, cleaned thor-
ration of the tooth during dental procedures. oughly, and disinfected with a chemical germicide.
This handpiece contains a friction-grip chuck; All tubings must be wiped with a disinfectant.
therefore, only friction-grip, or FG, burs can The burs should be cleaned well with a bur brush
be used. A bur tool/wrench or a button release and then sterilized. Manufacturer’s recommen-
lever on the handpiece is used to insert and dations must be followed when sterilizing burs
remove the burs. When this handpiece is used, because different types of materials used in burs
intense heat is generated by the friction action require different methods of sterilization. Both
of the bur. This requires the handpiece to be low-speed and high-speed handpieces require
lubrication. It is important to follow the manu-
facturer’s instructions regarding the type of lubri-
A
cation and method of application.
CAUTION: Because of possible contamina-
tion from saliva, blood, or body fluids, stan-
dard precautions must be observed while
B handpieces are in use. Gloves, masks, and protec-
tive eyewear must be worn at all times. Gloves
FIGURE 18-25 (A) A friction grip (FG) bur has a and masks are discarded after each patient. In
smooth shank. (B) A latch-type bur has a groove.
addition, masks must be changed any time they
become wet or are worn for longer than 30 min-
utes. Protective eyewear must be disinfected,
rinsed to remove the disinfectant, and dried
before being used for another patient.
The dental assistant’s responsibilities for the
use and maintenance of dental equipment vary.
It is your responsibility to learn exactly what
maintenance is expected. Read specific manu-
facturer’s instructions for the equipment you
handle.

FIGURE 18-26 A high-speed handpiece is used the assignment sheet for 18:6, Operating and
to do most of the cutting and preparation of the Maintaining Dental Equipment. Then return and
tooth during dental procedures. continue with the procedure.
580 CHAPTER 18
PROCEDURE 18:6
leave the disinfectant in place for the
Operating and amount of time recommended by the
Maintaining Dental manufacturer. Then rewipe all areas.
Remove the gloves, and wash your
Equipment hands. Then, apply clean protective
barriers.
Equipment and Supplies e. Use a mild detergent and a soft cloth
Dental light, dental chair, air compressor, oral- to clean the shield of the light.
evacuation system, assistant’s cart with equip- f. Locate all moving parts on the light
ment, doctor’s cart with equipment, latch-type fixture. Use a general, all-purpose oil
bur, friction-grip (FG) bur, bur tool, lubricants, to lubricate these parts, if lubrication
cleaning brush, soft cloths, disinfecting solu- is needed.
tion, protective barriers, disposable gloves 4. Practice operating the dental chair:
a. Locate the chair lock. It is usually on
Procedure the base of the chair. Lock and unlock
the chair.
CAUTION: The chair must be locked
2. Wash hands. Put on gloves. If the equip- when a patient is getting in or out of it.
ment will be operated, a mask, gown, and
protective eyewear must also be used. b. Locate the elevation control, which
raises and lowers the height of the
CAUTION: Dry hands thoroughly. You chair. It is usually a foot control on
will be working with electrical equip- the base of the chair. Raise and lower
ment. the chair.
3. Practice operating the dental light: CAUTION: The chair must be in its
a. Locate the on/off switch. Turn the lowest position when a patient is get-
light on. ting in or out of the chair.
b. Position the light so that it is above NOTE: At least once each week, the
the dental chair. From a seated posi- chair should be elevated to its highest
tion, practice moving the light. position and then lowered to its
NOTE: You will be sitting on a chair lowest position. This lubricates the
while assisting the doctor and will hydraulic system.
frequently reposition the light. c. Locate the forward-backward con-
trol, which reclines or raises the back
c. Locate the dimmer switch. Turn the
of the chair. It is usually located on
switch to adjust the intensity of the
the side of the chair and near the
light.
headrest or on a foot control. Put the
d. Practice applying protective barriers chair in a reclining position. Raise
to the handles and/or switches of the the chair to a sitting position.
light. Use commercial covers, plastic
NOTE: The chair must be in an
wrap, or aluminum foil to cover and
upright position when a patient is
protect the areas of the light that may
getting in or out of it.
be touched during a dental proce-
dure. d. Locate the reset button, found on
many chairs. It is usually located near
CAUTION: Remember to wear gloves the forward-backward control. Oper-
while removing contaminated pro- ate the button. It automatically raises
tective barriers. After the covers are the back of the chair to an upright
discarded, wipe the areas with a disposition and lowers the chair to its
infectant. Then respray the areas and lowest position from the floor.
PROCEDURE 18:6
e. Place a clean, disposable cover on the f. If the air compressor does not have an
headrest and back of the chair. Some automatic rain valve, locate the drain
offices also drape the armrests and faucet or valve on the bottom of the
other parts of the chair with plastic- main tank. Check the pressure gauge
backed paper or plastic wrap. Wear to be sure it is at zero. Open the faucet
gloves to remove contaminated pro- or valve to allow the water that has
tective barriers, wipe the areas with a accumulated in the tank to drain.
disinfectant, respray the area and CAUTION: Do not open this valve
leave the solution in place for the unless the pressure is at zero.
correct amount of time, and then
NOTE: A pan can be placed under the
rewipe. Remove the gloves, and wash
tank to catch the draining water.
your hands before putting clean pro-
tective barriers in place. 6. Practice operating and maintaining the
oral-evacuation system:
f. Use a mild detergent and a soft cloth
to wash the chair. Rinse and dry the a. Read the manufacturer’s instructions.
chair. b. Turn the system on. Some systems
NOTE: Some manufacturers recom- have on/off switches in the dental
mend special upholstery cleaners. units; other, smaller systems have
switches on the evacuation units
5. Practice operating and maintaining the
themselves.
air compressor:
c. Turn the system off.
a. Read the manufacturer’s instructions.
d. Locate the solids collector trap.
b. Turn the compressor on. Most com-
Empty any particles in the trap onto
pressors are operated by a switch in
a paper towel. Place the towel and
the operatory area. Others must be
particles in the proper waste con-
turned on manually by plugging in
tainer. Wash the trap with a mild
an electrical cord. Before inserting
detergent, rinse, and dry. Replace the
the plug into an electrical socket,
trap on the system.
always check the electrical cord for
breaks or tears, and the plug for the CAUTION: Always wear gloves when
third prong. Some air compressors emptying the solids collector trap.
operate immediately after being NOTE: Many manufacturers recom-
plugged into an electric wall socket; mend using a germicide spray or
others have on/off switches. solution in the trap to prevent the
c. Watch the pressure gauge on the com- growth of organisms and the devel-
pressor. If the pressure goes above 120 opment of unpleasant odors.
pounds, turn the compressor off, and NOTE: Systems vary, so follow indi-
notify your doctor immediately. vidual instructions on removing and
NOTE: Most air compressors are set replacing the trap.
to provide 100 pounds of pressure. 7. Practice operating the tri-flow, or air–
d. Turn the compressor off. water, syringe. It is located on the assis-
tant’s cart and/or the doctor’s cart.
e. Locate the oil reservoir, if the air com-
pressor has one. Remove the cap or a. Push the button to release air. It is
plug. Check the level of oil. If the oil usually marked with an A (for air).
level is low, notify your doctor imme- b. Direct the tip of the syringe into a
diately. cup or sink. Push the button to
NOTE: Most air compressors are sealed release water. It is usually marked
units and require no lubrication. with a W (for water).
582 CHAPTER 18
PROCEDURE 18:6
c. Continue to hold the tip over a cup or the cart or on the tubing. Empty the
sink. Push both the air and water but- particles in the screen onto a paper
tons. Water under air pressure will towel. Place the towel and particles
spray out of the syringe. in an infectious-waste bag/can.
d. Remove and replace the syringe tip. Scrub the screen gently with a brush.
The tip must be sterilized after each Rinse the screen and replace it in the
patient. Some plastic tips are dispos- evacuator unit. Some screens are dis-
able and are discarded in an infec- posable. These are discarded in an
tious-waste container. infectious waste container and
replaced with a new screen.
e. Use a disinfectant solution to clean
the tip holder and tubing. NOTE: Follow specific instructions on
removing and replacing the screen.
8. Practice operating the saliva ejector:
e. Remove the tip. Place a disposable
a. Insert a tip into the ejector.
tip in an infectious-waste bag. Scrub
b. Locate the screw knob or control and a metal tip, using a brush to clean the
turn the ejector on. inside. Rinse the tip. Sterilize it cor-
NOTE: The oral-evacuation system rectly.
must be on before the ejector will f. Use a disinfectant solution to clean
work. the tip holder and tubing.
c. Turn the ejector off. g. Turn the evacuator on. Place the tip
d. Remove the tip. The tips are disposable into a disinfecting and deodorizing
and are placed in an infectious-waste solution to draw the solution into the
bag/can after being used on a patient. tubing to sanitize it.
e. Use a brush to clean inside the ejector 10. Practice maintaining the low-speed hand-
tip holder. Use a disinfectant solution piece. It is located on the doctor’s cart.
to clean the tip holder and tubing. a. Read the manufacturer’s instructions.
f. Turn the saliva ejector on. Place the b. Insert a contra-angle head or attach-
end into a disinfecting and deodor- ment on the handpiece. Tighten the
izing solution to draw the solution handpiece to hold the head in place.
into the ejector unit to sanitize it.
NOTE: The handpiece should be kept
9. Practice operating the HVE. open when an attachment or head is
a. Insert a tip into the evacuator. Tips not in place. If the handpiece is closed
can be plastic or metal. while empty, the units that hold the
b. Locate the slide valve. Move the valve heads in place are destroyed.
to turn the evacuator on. Move it in c. Check the contra angle to determine
the opposite direction to turn the which type of bur is required. If a
evacuator off. small latch is present on the back,
c. Remove the slide valve from the evac- latch-type burs are required. Obtain
uator. Scrub it with a brush. Rinse it a bur that has a groove at the end and
thoroughly. Dry the valve. Place a sili- insert it in the contra angle. Close the
cone lubricant on the valve. Replace latch to hold the bur in place. If no
the valve in the evacuator unit. latch is present on the contra angle,
friction-grip, or FG, burs are required.
NOTE: The lubricant prevents the Obtain an FG bur. Use a bur tool to
slide valve from sticking. push the bur into position on the
d. Locate the filter screen on the evacu- contra angle.
ator unit. It is usually located under
PROCEDURE 18:6
NOTE: Some new handpieces have a. Use a bur tool to insert and remove a
levers that are pushed to insert and friction-grip bur on the handpiece.
remove burs. Bur tools are not used with NOTE: Only friction-grip burs are used
these handpieces. in this handpiece.
d. Remove the bur from the contra angle NOTE: Some new handpieces have
by releasing the latch, pushing the bur levers that are pushed to insert and
out with the bur tool, or using the lever remove burs. Bur tools are not used with
on the handpiece, if a lever is present. these handpieces.
e. Remove the contra angle from the hand- b. Remove the handpiece from the unit.
piece by loosening the top of the hand- Scrub it thoroughly to remove debris,
piece. Use a low-speed lubricant to rinse and dry it, and then sterilize it. Use
lubricate the contra angle. Spray the a disinfectant to clean the outside of the
lubricant into the hole at the end, where tubing.
the contra angle attaches to the hand-
c. Follow manufacturer’s instructions to
piece.
lubricate the handpiece. Most hand-
f. Insert and remove a prophylaxis angle pieces are unscrewed at the base. Spray
on the handpiece. Use a low-speed high-speed lubricant into the large hole
lubricant to moisten the hole at the end only. Reassemble the handpiece. Oper-
of the prophylaxis angle, where the ate the handpiece to remove excess
angle attaches to the handpiece. lubricant. Wipe the handpiece dry with
g. Remove the handpiece from the unit. a paper towel and then clean the hand-
Scrub it thoroughly to remove debris, piece again with a disinfectant.
rinse and dry it, and then sterilize it. Use 12. Clean and replace all equipment.
a disinfectant to clean the outside of the
13. Wash hands.
tubing. Follow manufacturer’s instruc-
tions to sterilize the burs and the contra
angle or prophylaxis angle.
h. Follow manufacturer’s instructions to
lubricate the handpiece. Most hand-
pieces unclip in the center. Spray low-
speed lubricant into the lower end of
the top section; the tubing looks like two Practice
Vs in this area. Then, unscrew the hand- Go to the workbook and use the
piece from the base. The lower end of evaluation sheet for 18:6, Operating
this section has four holes. Spray low- and Maintaining Dental
speed lubricant into the second largest Equipment, to practice this
hole only. Reassemble the handpiece. procedure. When you believe you
Push the rheostat, or foot control, on have mastered this skill, sign the
the cart to operate the handpiece and to sheet and give it to your instructor
remove excess oil. Turn it off and use a for further action.
paper towel to wipe the handpiece dry.
Then, clean the handpiece again with a
disinfectant.
NOTE: Most manufacturers recommend
daily lubrication. Final Checkpoint Using the criteria
11. Practice maintaining the high-speed listed on the evaluation sheet, your
handpiece: instructor will grade your performance.
584 CHAPTER 18
18:7 INFORMATION
Identifying Dental Instruments
and Preparing Dental Trays
Assisting with a variety of dental procedures may
be one of the responsibilities of the dental assis-
tant. Correct preparation includes setting up
trays of instruments and supplies used in specific
procedures. Therefore, a dental assistant must be
familiar with dental instruments.
Various methods are used for setting up trays
for specific dental procedures. In some settings,
the trays are set up immediately before use. The
dental assistant prepares the room, seats the
patient, and then sets up a tray with supplies and
sterilized instruments. The instruments and sup-
plies are determined by the procedure that will be
performed on the patient. In other settings, preset
sterilized trays are used. Tray contents are deter- FIGURE 18-27 Instruments are arranged in order
mined by the doctor. Trays are set up for oral of use to make it easier for the dental assistant to
locate them.
examinations, amalgam restorations, composite
restorations, surgical extractions, and other simi- rated, or smooth working end of a condensing
lar procedures. During an oral examination, the (packing) instrument; a point is the sharp end
patient’s teeth are cleaned and examined. Dental used to explore and detect.
radiographs or X-rays may be taken. Amalgam
and composite are the two main restorative mate-
♦ Shank: The portion that connects the shaft, or
handle, to the blade, nib, or point.
rials used to repair carious lesions or tooth decay.
The doctor removes the damaged tooth structure ♦ Shaft: The handle of the instrument, usually
and creates an opening called a cavity prepara- hexagonal (six sides) to provide a better grip.
tion. Amalgam, the silver restorative material, or Some instruments are single ended; which
composite, an esthetic restorative material is then means they have only one working end with a
placed in the cavity preparation. A surgical extrac- blade, nib, or point. Other instruments are dou-
tion is removal of a damaged tooth. After deter- ble ended; which means they have a working
mining the procedure that is to be performed, the edge on each end of the instrument. Some
dental assistant seats the patient and positions double-ended instruments have the same type of
the correct tray containing the sterilized instru- working surface at each end, but one end is larger
ments. Additional instruments or supplies can be than the other. Others have one working end for
added if needed. In many settings, preset trays are the right side of a preparation and the second end
color coded (for example, red for amalgam, blue for the left side. In some cases, an instrument has
for composite) and are sterilized as a unit. ends with different functions, but both ends are
Items on the trays should be organized and used for the same procedure.
placed in proper sequence. Instruments are usu- Instruments used vary from office to office.
ally arranged in the order of use. After an instru- However, some instruments are standard and are
ment is used, it is returned to the same place on used in all dental offices. The following list briefly
the tray, in case it is needed again. This makes it describes some of the main instruments.
easier for the dental assistant to locate instruments
and increases overall efficiency (figure 18-27). ♦ Mouth mirror: Used to view areas of the oral
The main parts of a dental hand instrument cavity, reflect light on dark surfaces, and retract
are: the lips for better visibility. It is used in every
basic tray set up. Mirrors are available in vari-
♦ Blade, nib, or point: A blade is the cutting porous sizes and with plain or magnifying ends
tion of an instrument; a nib is the blunt, ser- (figure 18-28).
FIGURE 18-28 Mouth mirror.
♦ Explorer: Used to examine the teeth, detect

carious lesions, and note other oral condi-
tions. Explorers are available in many shapes
FIGURE 18-30 Nonlocking cotton pliers.
and sizes. They may be single or double ended
(figure 18-29).
an expro has an explorer at one end and a
♦ Cotton pliers: Used to carry objects such as periodontal probe at the other end (figure
cotton pellets or rolls to and from the mouth. 18-32B).
Some lock, some do not. They are also called
operating pliers or college pliers (figure 18-30).
♦ Excavators: Used mainly for removal of caries
and refinement of the internal opening in a
♦ Scalers: Sharp instruments used to remove cavity preparation (figure 18-33).
calculus (tartar) and debris from the teeth and (1) Spoon: Used to remove soft decay from a
subgingival pockets. Scalers are used mainly cavity. It is also used to remove excess
for prophylactic (cleaning) or periodontal dental cement. It is a cutting instrument
(gum, or gingiva) treatments. They are avail- with a small curve or scoop at the working
able in many types or shapes (figure 18-31). end.
♦ Periodontal probes: Used to measure the depth (2) Hoe: Used primarily on anterior teeth to
of the gingival sulcus (the space between the remove caries, smooth and shape a cavity
tooth and the free gingiva). It has a round, preparation, and/or form line angles. A
tapered blade with a blunt tip that is marked hoe has one or more angles to the shaft,
in millimeters (mm) (figure 18-32A). A com- with the last length forming the blade. It is
bination double-ended instrument called also used in scraping, planing, and direct-
thrust cutting.
FIGURE 18-31 Types of scalers: (A) Sickle and

FIGURE 18-29 Double-ended explorer. Jacquette; (B) Sickle; (C) Jacquette.
586 CHAPTER 18
FIGURE 18-32A Periodontal probe. (Courtesy of Miltex Instrument Co., Inc., Lake Success, NY)
A B
FIGURE 18-32B An expro is a combination instrument with (A) an explorer at one end and (B) a periodon-
tal probe at the other end. (Courtesy of Miltex Instrument Co., Inc., Lake Success, NY)
(3) Hatchet: Used to refine internal line angles, ♦ Chisels: Used for cutting and shaping enamel.
smooth and shape the sides of a cavity Instruments in this group include:
preparation, and remove hard-type caries. (1) Enamel hatchet: Similar to other hatchets
It is usually a double ended right and left but the blade is larger, heavier, and bev-
instrument. eled on only one side.
(2) Gingival margin trimmer: Special chisel
for placing bevels on gingival enamel mar-
gins of proximoocclusal cavity prepara-
tions. Most are double ended for either the
distal or mesial side of the tooth. It has the
chisel blade placed at an angle to the shaft,
not straight across like a hatchet. In addi-
tion, the blade is curved, not flat like a
hatchet (figure 18-34).
♦ Cleoid-discoid carver: A double-ended cutting
instrument. It is also available as a cleoid or
discoid single-ended instrument. The cleoid
has a claw-shaped cutting end, and the cut-
ting edge surrounds the entire end. The dis-
coid is disc shaped and also has the cutting
edge around the blade. It is used as a carver
for amalgam, but can also be used as an exca-
vator (figure 18-35).
A. B.
♦ Plastic filling instrument (PFI): Used to shape
and condense restorative material that is still
malleable (capable of being shaped or formed).
It is also used with cements before setting
occurs. Most have a small condenser at one
B
C. FIGURE 18-34 Gingival margin trimmers: (A)
FIGURE 18-33 Excavators: (A) spoons, (B) hoes, distal; (B) mesial. (Courtesy of Hu-Friedy Mfg. Co.,
and (C) hatchets. Inc.)
A. B.
FIGURE 18-35 Carvers: (A) cleoid and (B) discoid. (Courtesy of Hu-Friedy Mfg. Co., Inc.)
end and a paddle-like cutting blade at the

other end (figure 18-36). FULL
♦ Amalgam instruments: Used mainly with

SIZE
amalgam restorations. Some examples are as

follows:
(1) Amalgam carrier: Used to carry small Yellow
Band
masses of freshly mixed amalgam to the
cavity preparation (figure 18-37).
(2) Amalgam carvers: Used to carve or shape
freshly placed amalgam and restore the
tooth to natural anatomy. One example is
the Hollenback carver (figure 18-38).
(3) Condenser–plugger: Used for condensing
and packing amalgam into the prepared
cavity. The ends may be serrated or plain
(figure 18-39).
(4) Matrix retainer and matrix band: The Red
matrix retainer is used to hold the matrix Band
band in place (figure 18-40). A matrix band

is a short strip of steel or other metal that
is not affected by mercury. It is used to
form a wall around a cavity so amalgam FULL
can be packed into place. A. SIZE B.
FIGURE 18-37 Amalgam carriers: (A) lever type
NOTE: Plastic matrix strips are used with and (B) plunger type. (Courtesy of Miltex Instrument
composite restorative material. Co., Lake Success, NY)
♦ Burnisher: Contains working points in the
shapes of balls or “beavertails.” Burnishers are
used primarily to burnish (adapt) the margins
♦ Plastic composite instruments: A set of plastic
instruments used with composite restora-
of gold restorations to a better fit. Burnishers
tions. Because metal instruments can discolor
are also used to polish other metals (figure
composite, doctors use plastic instruments.
18-41).
♦ Surgical instruments: Instruments used
depend on the type of oral surgery being per-
formed. The main instruments used in extrac-
tion procedures are listed. Other specific
instruments and supplies such as chisels,
hemostats, needle holders, and suture materi-
als might also be used.
(1) Surgical forceps: Also called extracting for-
FIGURE 18-36 Plastic filling instruments (PFIs). ceps. These are used for extracting teeth.
588 CHAPTER 18
FIGURE 18-38 Hollenback carver. (Courtesy of Hu-Friedy Mfg. Co., Inc.)
FIGURE 18-39 Condenser–plugger. (Courtesy of Hu-Friedy Mfg.

Co., Inc.)
FIGURE 18-40 Matrix retainer and band.

FIGURE 18-42 Surgical forceps.
A
FIGURE 18-41 (A) Oval burnisher; (B) ball

burnisher.
There are many different types, one for

each type of tooth to be extracted (figure
18-42).
(2) Periosteal elevators: Used for lifting the
mucous membrane and tissue covering
the bone. It is a double-ended instrument
with a blade at each end (figure 18-43).
(3) Root (extraction) elevator: Used to loosen
the tooth out of its socket prior to being FIGURE 18-43 Periosteal elevators.
removed with forceps. There are various
types, shapes, and sizes (figure 18-44). (5) Rongeur forceps: Used to trim or cut bone
(4) Root-tip pick: Used to remove small tips tissue. The tips of the forcep may be round
from a socket such as a root tip or piece of or square with a tough sharp blade that
bone. There are straight and contra-angled extends around both sides and the end of
versions (figure 18-45). the tips (figure 18-46).
A B FIGURE 18-46 Rongeur forceps.

FIGURE 18-44 Root (extraction) elevators: (A)
apical (B) Potts or T-handled. (Courtesy of Miltex
Instrument Co., Inc., Lake Success, NY)
FIGURE 18-47 Bone or surgical chisel and

mallet.
Trays can be set up for a variety of dental pro-

cedures. Four examples of tray setups include:
FIGURE 18-45 Root-tip picks. ♦ Prophylactic, or general examination, tray:
This type of tray is used for basic examination
and cleaning of the teeth. Supplies and instru-
(6) Lancet: Used to lance and incise tissue. A
ments placed on the tray include scalers; a
lancet is similar to a scalpel and blade.
periodontal probe for an adult; prophylactic
(7) Bone or surgical chisels: Used for cutting
cups, paste, and brushes; and fluoride-
bone structure in oral surgery. Some are
treatment supplies.
used by hand, others require the use of a
surgical mallet (figure 18-47). ♦ Amalgam restoration tray: This type of tray is
used for an amalgam restoration procedure.
When setting up trays for various procedures, Instruments placed on the tray include amal-
it is important to remember to place only items gam carriers, condenser-pluggers, and carvers.
that are usually needed. Setting the tray with
instruments and supplies that are needed only ♦ Composite, or esthetic, restoration tray: This
occasionally can decrease efficiency and crowd type of tray is used for the placement of a
all the items. Items usually kept in the cart include composite restoration. Special composite
the drape and clips, dental bases and cements, instruments such as a fine brush and plastic
restorative materials, extra cotton products or instruments are placed on this tray.
dressings, and instruments used for specific ♦ Surgical extraction tray: This type of tray is
problems or procedures. Some instruments and used for extraction, or removal, of teeth.
supplies are placed on almost all trays. Examples Instruments and supplies vary depending on
include the mouth mirror, cotton pliers, explorer, the type of extraction. In most cases, however,
cotton pellets, cotton rolls, and gauze sponges. surgical instruments such as extracting for-
590 CHAPTER 18
ceps, root elevators, root-tip picks, periosteal STUDENT: Go to the workbook and complete
elevators, Rongeur forceps, lancets, bone chis- the assignment sheet for 18:7, Identifying Dental
els, and a needle holder with suture materials Instruments and Preparing Dental Trays. Then
are placed on the tray. return and continue with the procedure.
PROCEDURE 18:7
g. hoes
Identifying Dental
Instruments and h. hatchet
Preparing Dental Trays i. enamel hatchet

j. gingival margin trimmer
Equipment and Supplies k. cleoid-discoid carver
Patient records, radiographs (X-rays), variety l. plastic filling instrument

of instruments; cotton pellets and rolls; tray m. amalgam carrier
for supplies and instruments; cements; mix- n. amalgam carvers
ing pads; drape and clips; carts with hand-
pieces; assorted supplies and equipment for o. condenser–plugger
specific procedures, personal protective p. matrix retainer and band
equipment (PPE) including gloves, gown,
q. burnisher
mask; and eye shield
r. plastic composite instruments
Procedure s. surgical forceps
t. periosteal elevator
u. root (extraction) elevator
2. Wash hands. Put on required personal
protective equipment (PPE) including v. root-tip pick
gloves, a gown, mask, and eye shield. w. Rongeur forcep
3. Read the Information sections on den- x. lancet
tal instruments, amalgam, composite, y. bone or surgical chisel and mallet
cements, and anesthesia.
6. Set up trays for the following proce-
4. Place the dental tray in a convenient dures: prophylactic cleaning and oral
location. Make sure the tray is clean. examination, amalgam restoration,
5. Examine each of the following instru- composite restoration, and surgical
ments until you are able to identify them extraction. Perform the following steps
and state why they are used. Refer to the for each procedure and tray.
information on Identifying Dental a. Lay out the general patient equip-
Instruments to complete this task. ment, including records, radiographs
a. mouth mirror (X-rays), drape, clips, and other simi-
lar items.
b. explorers
b. Review the parts of the carts. Think
c. cotton pliers
about which handpieces will be used.
d. scalers Make sure all are in good working
e. periodontal probe condition.
f. spoons
PROCEDURE 18:7
c. Set the tray with the main instru- 7. Review all of the equipment and sup-
ments to be used. Place these instru- plies you have prepared for each of the
ments in the order of use. Refer to four procedures (figure 18-48). Read the
references and Information sections steps of each procedure and make sure
to be sure you include all required that you have the equipment and mate-
instruments. Make sure that the basic rials the doctor will require for each.
instruments (mirror, explorer, cotton
8. If your doctor uses a rubber dam (a
pliers) are on the tray.
device to keep the oral cavity dry during
d. Have the correct dental cements or a procedure) or special types of anes-
bases available for any procedure thesia, be sure that you have prepared
that might involve the use of these these materials.
materials. Do not forget to have mix-
9. Remember that equipment, supplies,
ing pads and instruments ready for
and instruments used vary from doctor
use.
to doctor. It is the dental assistant’s
e. Think about additional equipment responsibility to know the doctor’s pref-
that might be used. Add these to the erences and to prepare these things for
tray. Such items might include pro- use.
phy paste, fluoride trays, matrix
bands, wooden wedges, finishing
strips, and articulation paper. 11. Remove PPE. Wash hands.
f. Add additional equipment that might
be necessary. Examples might include
the amalgamator and special hand-
pieces.
g. Add needed supplies. These might
include cotton pellets, rolls, gauze, Practice
and other similar items. Go to the workbook and use the
evaluation sheet for 18:7,
Identifying Dental Instruments and
Preparing Dental Trays, to practice
FIGURE 18-48 Always double-check to make Final Checkpoint Using the criteria
sure all required instruments and supplies are listed on the evaluation sheet, your
on the tray before starting any dental procedure. instructor will grade your performance.
592 CHAPTER 18
chair, and before returning the patient to a sitting

18:8 INFORMATION position. Unexpected movements can frighten
the patient.
Positioning a Patient Before any dental procedure is performed, a
in the Dental Chair protective drape is placed over the patient’s chest.
Positioning a patient in the dental chair is one of This protects the patient’s clothing during the
the responsibilities of a dental assistant. Correct procedure. Most drapes have a paper side and a
positioning of a patient in the dental chair allows plastic side. The plastic side is placed against the
the doctor to complete dental procedures effi- patient’s clothing; the paper side is placed facing
ciently. In four-handed dentistry, the patient is up. In this way, the paper absorbs moisture and
placed in a supine, or lying-down, position. the plastic keeps moisture from soaking through
Before a patient gets in or out of the chair, the to the patient’s clothing.
chair must be locked in the upright position. The The patient should also be given safety
patient could be injured if the chair moves. Always glasses to wear during the procedure. This
check the chair to be sure it is in a locked position protects the patient’s eyes from spray and fluids
before seating a patient or before assisting a that might be present during a dental procedure.
patient out of the chair. After the procedure is complete, the safety glasses
The patient’s head rests on the upper, narrow must be cleaned and disinfected before being
headrest of the chair. Positioning the patient’s used on another patient.
head in this narrow section of the chair allows the After the patient is in the correct position, the
doctor and the dental assistant closer access to light should be positioned 30–50 inches from the
the oral cavity. Short adults and children must be oral cavity, or mouth. Care must be taken to
positioned in the chair starting with correct ensure that the light illuminates the mouth but
placement of the head first. does not shine in the patient’s eyes.
The chair must be elevated from the floor to When positioning a patient in the dental
the height that will allow both the doctor to be chair, it is important to show a friendly and
seated comfortably near the chair and the pleasant attitude toward the patient. Make the
patient’s head to be above the doctor’s lap. patient feel welcome and allow the patient to talk
After a patient has been seated in the chair, it about his or her interests. Knowledge about the
is best to recline the chair slowly. Lowering a patient allows the dental assistant to ask ques-
patient to a supine position quickly can cause tions such as, “How was your vacation?” or “How
dizziness, discomfort, and fear in some patients. did your basketball team do in the last game?”
It is best to lower the chair part way, pause to Displaying an interest in patients makes them
allow the patient time to adjust to the change in more at ease and less apprehensive. When a pro-
position, and then finish lowering the chair. The cedure is complete, a comment such as, “It was
chair should recline until the patient is lying good to see you again, Mrs. Brown” or, “I hope
almost flat. An imaginary line from the patient’s you enjoy your first year at college” is much bet-
chin to the patient’s ankles should be parallel to ter than, “You’re done for today.”
the floor. The patient’s nose and knees should be
at about the same level. STUDENT: Go to the workbook and complete
Explain all chair movements to the patient. the assignment sheet for 18:8, Positioning a Patient
Inform the patient before elevating or low- in the Dental Chair. Then return and continue
ering the chair, before reclining the back of the with the procedure.
PROCEDURE 18:8
Positioning a Patient
in the Dental Chair
Dental chair and light, headrest cover, drape,
alligator clips, protective barriers for dental
light, gloves, mask, protective eyewear for
dental personnel and the patient, disinfec-
tant solution, gauze sponges
Procedure
1. Wash hands.
2. Assemble equipment. Use a disposable
plastic cover to cover the headrest and/
or top of the chair. Use protective barri- FIGURE 18-49 A protective drape is used to
ers, such as commercial covers, plastic protect the patient’s clothing during dental
wrap, or aluminum foil to cover the procedures.
handles and/or switches of the dental
light, the handpieces, and the tubings. 8. Give the patient safety glasses to wear
Use plastic cloths to cover the tops of during the procedure.
dental carts.
9. Use the elevation control to raise the
3. Introduce yourself. Identify the patient. chair to the height desired by the doctor.
Explain the procedure. This is usually about 8–12 inches above
NOTE: Patients are often apprehensive. the seat of the doctor’s chair.
4. Lock the chair to prevent movement of NOTE: Tell the patient you are raising
the chair. the chair before doing so.
CAUTION: Double-check the lock to 10. Use the backward control to place the
prevent injury to the patient. patient in the correct reclining position.
Pause after reclining the patient halfway
5. Assist the patient into the chair. to allow the patient to adjust to the
6. Adjust the headrest for comfort and cor- change in position. When the patient is
rect position. fully reclined, the patient’s nose and
knees should be at about the same
7. Use the alligator clips to secure the
level.
drape around the patient’s neck and
shoulders (figure 18-49). Place the plas- NOTE: Inform the patient. Observe the
tic side of the drape against the patient’s patient closely for signs of respiratory
clothing. distress.
NOTE: The drape can also be applied 11. Position the light 30–50 inches from the
later, when the patient is in a reclining oral cavity. Leave the light off until the
position. doctor is ready to work on the patient.
NOTE: In some offices, the patient’s NOTE: Make sure the light does not
health history is updated at this time. shine in the patient’s eyes.
594 CHAPTER 18
PROCEDURE 18:8
12. Put on gloves, a gown (if not wearing tion to wipe all contaminated areas.
protective clothing), a mask, and pro- Then respray all areas, leave the disin-
tective eyewear before assisting the doc- fectant in place for the required amount
tor with any dental procedure that may of time, and rewipe the areas.
result in the splashing of saliva, blood,
18. Clean and prepare all instruments and
or body fluids.
handpieces for sterilization. Replace all
CAUTION: Observe all standard precau- equipment.
tions while assisting with dental proce-
19. Remove and discard gloves. Wash hands
dures.
thoroughly.
13. When the doctor is done, lock the chair.
Check to be sure it does not move. Posi-
tion the dental light out of the patient’s
way.
14. Warn the patient not to get out of the
Practice
chair until it has stopped moving. evaluation sheet for 18:8,
15. Use the reset button to lower the chair Positioning a Patient in the Dental
and to return it to an upright position. Chair, to practice this procedure.
Remove the drape and place it in an When you believe you have
infectious-waste container. mastered this skill, sign the sheet
16. Help the patient out of the chair. and give it to your instructor for
further action.
17. After the patient has left the area, remove
the protective barriers from the light,
dental chair, handpieces, tubing, and Final Checkpoint Using the criteria
carts. Put the barriers in an infectious listed on the evaluation sheet, your
waste container. Use a disinfectant solu- instructor will grade your performance.
18:9 INFORMATION ♦ Prevention of halitosis (bad breath)

The importance of proper brushing and
Demonstrating Brushing and flossing techniques must be stressed to the
Flossing Techniques patient. Demonstrations should be given to all
Using correct brushing and flossing techniques is patients. Talk slowly and clearly. Repeat and stress
essential to prevent dental disease. Teaching the important points.
patient the correct methods to use is part of the The brushing technique taught will depend
responsibility of a dental assistant. on the preference of the doctor. A common tech-
Correct brushing and flossing are important nique is the Bass method. The brush is placed at
parts of prophylactic (preventive) care. Purposes a 45-degree angle to the gumline, and then a
include: vibrating motion is used.
Five surfaces on each tooth must be
♦ Prevention of decay, or carious lesions (car- cleaned:
ies)
♦ Removal of plaque; plaque is a thin, ♦ Chewing or biting surface: the top surfaces of
tenacious, filmlike deposit that adheres the teeth
to the teeth and can lead to decay; plaque ♦ Facial surface: the tooth side that faces the
contains microorganisms and a protein sub- inside of the lips and cheeks; facial surfaces
stance are seen from the front, as in a smile
♦ Lingual surface: the tooth side nearest the tors recommend toothpaste with fluoride. The
tongue American Dental Association supports the use of
fluoride as an aid in preventing decay. Tooth-
♦ Side, or interproximal, surfaces: the surfaces pastes with tartar control help prevent the hard
located between the teeth; there are two on
deposits that accumulate on the teeth. Tooth-
each tooth; floss is used to clean these sur-
pastes with whitening agents help remove stains
faces because a brush cannot get between the
from teeth. The type of toothpaste recommended
teeth, and the bristles do not provide enough
to the patient depends on the needs of the patient
coverage
and the doctor’s preference.
Toothbrushes vary in size, shape, and texture Dental floss is used to remove plaque and
of the bristles. A soft-bristled brush is usually rec- bacteria from the side surfaces of the teeth. Floss
ommended. It will not injure the gum, or gingival is available in waxed and unwaxed types. The
tissue. The head of the brush should be the cor- type suggested to the patient depends on the
rect size and fit easily into the mouth. Brushes doctor’s preference. Both types are effective if
should be discarded when the bristles are frayed used correctly.
or worn. Many kinds of electric toothbrushes are
also available and are effective in cleaning the
teeth if used correctly. They can be very beneficial
for people with limited function of the hands and STUDENT: Go the workbook and complete the
arms, such as people with arthritis. assignment sheet for 18:9, Demonstrating Brush-
Toothpastes or dentrifices are used to clean ing and Flossing Techniques. Then return and
the teeth and provide a pleasant taste. Many doc- continue with the procedures.
PROCEDURE 18:9A
NOTE: If the doctor has recommended
Demonstrating another type of toothbrush, follow the
Brushing Technique doctor’s preference.
6. Use a toothbrush and demonstration
Equipment and Supplies model of teeth to show the patient how
to brush the teeth.
Soft-textured toothbrush, demonstration
model of teeth 7. Tell the patient to begin brushing in one
area of the mouth and then to system-
Procedure atically brush each tooth. Suggest start-
ing on the facial surfaces of the right,
1. Assemble equipment. rear teeth.
2. Wash hands. 8. Place the brush at a 45-degree angle to
the gumline (figure 18-50A).
9. Rotate the brush slightly and gently
4. Explain the importance of correctly
push the bristles between the teeth.
brushing the teeth. Stress that proper
brushing helps prevent decay and 10. Use a very short, back-and-forth, light
removes plaque, a soft deposit leading vibrating movement to clean the teeth.
to decay. Also stress that teeth should be 11. Move the brush to the next group of
brushed immediately after eating. teeth. Repeat steps 8–10. Continue until
5. Suggest the use of a soft-textured brush the facial surfaces of all the teeth are
to prevent gum damage. clean.
596 CHAPTER 18
PROCEDURE 18:9A
12. Repeat steps 8–10 on the lingual, or
tongue, surfaces of the teeth. To brush
the lingual surfaces of the front, or ante-
rior, teeth, place the brush in a vertical
position (figure 18-50B).
13. Brush the biting surfaces of all teeth.
Place the brush on the surfaces. Use a
very short, vibrating motion (figure 18-
50C). Move the brush to the next area.
Repeat until all biting surfaces are
clean.
14. Stress to the patient that the areas
between the teeth must be cleaned with
FIGURE 18-50C Use a short, vibrating
motion to clean the biting surfaces of the teeth.
floss.
15. Ask whether the patient has any ques-

tions. Make sure the patient under-
stands the technique to use.
NOTE: Asking the patient to demon-
strate the technique is a good method of
determining whether the main points
have been understood.
16. Clean and replace all equipment.
17. Wash hands.
FIGURE 18-50A Place the brush at a 45-

degree angle to the gumline.
Practice
Demonstrating Brushing Technique,
to practice this procedure. When you
FIGURE 18-50B Hold the brush in a vertical Final Checkpoint Using the criteria
position to clean the lingual, or tongue, surfaces listed on the evaluation sheet, your
of the anterior teeth. instructor will grade your performance.
PROCEDURE 18:9B
Demonstrating
Flossing Technique
Dental floss, demonstration model of teeth
Procedure
2. Wash hands.
3. Introduce yourself. Identify the patient. FIGURE 18-51A To floss maxillary teeth,
wrap the floss around the index finger of one
4. Explain the importance of flossing. hand and the thumb of the other hand or use
Stress that flossing is the way to remove the two thumbs.
food and plaque from between the teeth.
Mention that this is an area where decay
often begins because brushing is not
enough. A toothbrush cannot clean
these areas.
5. Use dental floss and a demonstration
model of the teeth to show the patient
how to floss the teeth.
6. Remove 12–18 inches of floss from the
spool.
NOTE: Floss is waxed or unwaxed. The
type recommended depends on the
doctor’s preference. FIGURE 18-51B To floss mandibular teeth,
7. Wrap the floss around the middle fin- wrap the floss around the two index fingers.
gers of both hands. This anchors the
floss. As floss is used, unroll new floss
from the middle finger of one hand and
wrap used floss around the middle fin-
ger of the opposite hand.
8. To clean the maxillary (upper) teeth,
wrap the floss around the index finger of
one hand and the thumb of the other
hand or the two thumbs (figure 18-51A).
To clean the mandibular (lower) teeth,
use the index fingers of both hands (fig-
ure 18-51B).
NOTE: Floss still remains anchored on
middle fingers. FIGURE 18-51C After curving the floss into a
C-shape around the side of the tooth, use an
up-and-down motion to clean the side.
598 CHAPTER 18
PROCEDURE 18:9B
9. Keep the fingers and thumb approxi- times teeth are flossed. If bleeding or
mately 1–2 inches apart. This is the soreness continues, flossing should be
length of floss to be used. stopped and the doctor notified.
10. Gently insert the floss between the teeth. 15. Make sure the patient understands the
Do not snap the floss into the gums. procedure.
CAUTION: Snapping the floss into the NOTE: Asking the patient to demon-
gums can injure the gum tissue. strate the technique is a good way to
determine whether the main points
11. Gently slide the floss into the space
have been understood.
between the gum and tooth. Stop when
you feel resistance. Curve the floss into 16. Clean and replace all equipment.
a C-shape around the side of the tooth
17. Wash hands.
(figure 18-51C).
12. Hold the floss tightly against the tooth
and move the floss away from the gum
by scraping the floss up and down
against the side of the tooth to remove Practice
plaque and debris. Go to the workbook and use the
CAUTION: A side-to-side or front-to-
back motion could cut the gums. Demonstrating Flossing Technique,
13. Repeat steps 10–12 until both sides of believe you have mastered this skill,
every tooth in the mouth have been sign the sheet and give it to your
flossed. Move the floss on the fingers as instructor for further action.
it becomes soiled or after finishing the
side of a tooth. Use fresh floss at all
times.
14. Warn the patient that some bleeding listed on the evaluation sheet, your
and soreness may occur the first few instructor will grade your performance.
18-52). It is taken to form a model of the area for

18:10 INFORMATION restorative treatment that will take place outside
of the mouth. Common materials used to take
Taking Impressions impressions are alginate, rubber base, and the sili-
and Pouring Models cones such as polysiloxane or polyvinylsiloxane.
A model, also called a cast, is a positive
INTRODUCTION reproduction of the arches or teeth that is created
from the negative impression (figure 18-53).
The dental assistant may prepare a wide variety Common materials used for models are plaster
of impression and model materials for the doc- or stone. A model serves as the basis for construc-
tor. This section provides basic facts about the tion of dentures, partials, or other prosthetics for
purposes and types of some of these materials. the mouth. A model is also used for making orth-
An impression is a negative reproduction of odontic appliances, mouth guards, and custom
a tooth, several teeth, or the dental arch (figure trays.
Disadvantages include:
♦ It is not good for final impressions of cavity
preparations or small areas requiring fine
detail, such as final impressions for crowns or
bridges.
♦ It changes in dimension by shrinking as it
loses water content and must be poured
immediately for an accurate duplication.
♦ It tears or breaks easily when set.
Alginate powder is supplied as a fast set (type
I) or regular set (type II), flavored or unflavored,
and/or regular or heavy-bodied material. Some
alginates have an antimicrobial agent added to
prevent the growth of microorganisms in the
FIGURE 18-52 An impression is a negative impression. Some are powder-free to reduce
reproduction of a tooth, several teeth, or a dental
inhalation of the dry material.
arch.
Proper measuring techniques are essential to
obtain the correct set. Always follow the manu-
facturer’s directions. Some manufacturers require
that the alginate powder be fluffed (shake the can
lightly with the lid on) before being put in the
powder scoop. Others require packing the pow-
der into the scoop. It is also essential to measure
the water carefully and to use the measuring con-
tainer provided by the manufacturer. Inaccurate
measurements of the powder and water can affect
the setting time, strength, and accuracy of the
final impression. Alginate material should be
stored in a cool, dry place to avoid deterioration.
FIGURE 18-53 A model is a positive reproduction The lid should be replaced immediately after the
of the teeth that is used for the construction of
material is used to prevent moisture contamina-
dentures, partials, or other prosthetics.
tion.
A new form of premixed alginate with a dis-
pensing unit may also be used. The premixed
ALGINATE alginate is loaded into the dispensing unit (figure
18-54). A disposable tip is attached to the end of
Alginate is an irreversible hydrocolloid impres-
the unit and the alginate is dispensed directly
sion material. It cannot be returned from a gel to
into the impression tray. This type of alginate is
its original state. Advantages include:
more expensive, so it is not used as frequently as
♦ It is simple and economical to use. powdered alginate.
♦ Setting time can be controlled by the water
temperature.
♦ It has adequate strength for an accurate RUBBER BASE
impression. (POLYSULFIDE)
♦ It yields an adequate basic reproduction of
detail. Rubber base (polysulfide) is an elastomeric
impression material that is elastic and rubbery in
♦ It can be used for impressions of the teeth nature. It is supplied in two tubes of paste: a base
and/or tissue. and a catalyst (accelerator). Usually the two are
♦ It is easily removed from tissues and instru- mixed manually using a mixing pad and spatula.
ments during cleaning. There are special cartridges of rubber base mate-
600 CHAPTER 18
1–2 hours after they are made. Disadvantages of

rubber-base or polysulfide materials are the
sulfur-like odor, taste, long setting-time (approxi-
mately 10 minutes), and the fact that it causes
permanent stains on cloth and other materials.
SILICONES
Silicone impression materials include polysi-
loxane or polyvinylsiloxane. They are available in
light-bodied, regular (medium)-bodied, and
heavy-bodied versions. Silicones can be supplied
in two tubes, a base and an accelerator (catalyst),
which are mixed together manually. The most
common type of silicones for impressions are
cartridges of the base and accelerator, which are
placed in a special mixing device called an
extruder, or automix gun (figure 18-55A). A dis-
posable mixing tip is placed on the end of this
gun, and as the pastes are expelled into the mix-
ing tip, the accelerator (catalyst) and base are
automatically mixed. The mixed material can be
extruded directly into the impression tray (figure
18-55B). Syringe-tipped mixing tubes can also be
FIGURE 18-54 A newer but more expensive type used, and the material can be placed directly on
of alginate is premixed and can be dispensed the area of the impression as it is expelled from
directly into the impression tray. the gun. This provides for easy cleanup after use.
Polysiloxane or polyvinylsiloxane materials
rial that can be placed in an extruder gun. The are not affected by fluids in the oral cavity. This
extruder gun mixes the base and catalyst together allows these materials to spread evenly over the
and dispenses it directly into a tray and/or impression area, creating a highly accurate
syringe. impression. This impression retains its shape and
Three types are produced. One is a light- size for a long period. Another important advan-
bodied material for use in a syringe. The second tage is that these materials are odor-free and have
is a heavy-bodied material for use in trays. The a pleasant taste. One disadvantage is that latex
third is a regular- or medium-bodied material for gloves may inhibit the setting of these materials;
use in both syringes and trays. Frequently, two thus, vinyl gloves must be worn while taking
types are used together. A syringe is used to place
light-bodied material into the area of the impres-
sion. Then, a custom tray filled with heavy-bod-
ied material is placed into the mouth and over
the light-bodied material to complete the impres-
sion.
Rubber-base materials can be used for any
dental procedure that requires an impression.
They are particularly good for use in cavity prep-
arations that require fine detail, such as an
impression taken prior to the construction of a
crown. Rubber-base materials are not subject to FIGURE 18-55A An extruder gun automatically
dimension changes as much as are alginates. mixes the cartridges of catalyst and base of polysi-
However, rubber-base materials should be loxane or polyvinylsiloxane impression materials.
poured promptly if possible, preferably within (Courtesy of Kerr Corporation)
stone. If an insufficient amount of water is

used, the mixture will be too thick and crum-
bly to flow into the impression. If too much
water is used, the model will be weak, set
slowly, and develop air bubbles that destroy
the effectiveness of the model.
♦ Impressions should be clean and dry before
the models or casts are poured. Drying by
blotting is preferred. Drying with an air blast
can cause dehydration or shrinkage of the
impression material, especially of alginate.
♦ The use of cold water when mixing plaster
provides the greatest amount of working time.
FIGURE 18-55B The mixed silicone can be When you are learning how to prepare the
extruded directly into the impression tray. plaster mix, use the coldest water available to
provide more time.
♦ Air bubbles in the mix can ruin a model. Stir
and spatulate the mix in such a way that as
impressions. A second disadvantage is that they little air as possible enters the mix. To remove
are more expensive than rubber-base or polysul- as many air bubbles as possible, always place
fide impression materials. the bowl on a vibrator before pouring.
Because contact with saliva, body fluids,
GYPSUM MATERIALS and/or blood is very possible while taking
impressions and pouring models, the Centers for
There are two main gypsum products used to Disease Control and Prevention (CDC) has estab-
form models: plaster and stone. Plaster is the lished guidelines for infection control. Gloves, a
weaker of the two. It is used mainly where strength gown, face mask, and eye protection must be
is not a critical factor, such as for study models worn at all times. Hands must be washed imme-
and preliminary models. It is also a less expensive diately after removing gloves at the end of the
material. Stone is a more refined gypsum prod- procedure. All completed impressions must be
uct than is plaster. It produces a stronger, more rinsed gently for at least 30 seconds with room-
regular and uniform model. However, it is more temperature tap water to remove any mouth
expensive than plaster. Stone is used for making debris. The impression must then be disinfected
diagnostic models or casts and for any work with a solution such as 10-percent sodium hypo-
requiring a high degree of strength and accuracy. chlorite (household bleach), iodophor, glutaral-
Basic principles for the use of plaster and dehyde, or phenylphenol. All mixing containers,
stone include: spatulas, and impression trays must be disin-
fected or sterilized prior to being used for another
♦ Both products must be stored in a tightly patient. Standard precautions must be followed
closed container and in a cool, dry area. Mois- at all times while taking impressions and pouring
ture contamination of gypsum products leads models.
to defective models or casts.
♦ Correct amounts of water and powder must STUDENT: Go to the workbook and complete
be used. Usually, 45–50 milliliters (mL) of the assignment sheet for 18:10, Taking Impressions
water is used for 100 grams of plaster; 30 mil- and Pouring Models. Then return and continue
liliters (mL) of water is used for 100 grams of with the procedures.
602 CHAPTER 18
PROCEDURE 18:10A
several times if directed to do so by the
Preparing Alginate manufacturer. Open the lid cautiously
to avoid inhaling the powder, which can
Equipment and Supplies be hazardous if inhaled. Wearing a face
mask reduces this risk.
Alginate powder; large, rubber mixing bowl
or disposable mixing bowl; spatula; powder NOTE: Some brands of alginate are
scoop and water-measuring cup provided by packed into the scoop and not fluffed. It
the manufacturer; room-temperature water; is important to read and follow manu-
denture; impression trays; disinfectant solu- facturer’s instructions.
tion or spray; disposable gloves; gown; face 7. Measure out the correct amount of pow-
mask; eye protection der using the powder scoop provided by
the manufacturer. Fill the scoop with
Procedure powder. Tap the top of the scoop lightly
with the spatula to fill air voids. With the
1. Assemble equipment. Select an impres- spatula, level the powder at the top of
sion tray to fit the denture. the scoop (figure 18-56A).
NOTE: If an impression is being made of NOTE: Follow the manufacturer’s
the patient’s mouth, the doctor usually instructions for the correct amount of
measures and selects the impression powder. A basic guide is as follows:
tray to be used.
Three scoops: large maxillary impres-
2. Wash hands. Put on disposable gloves, a sion
gown, face mask, and eye protection.
Two scoops: medium maxillary or any
CAUTION: The denture or the mouth mandibular impression
will contain saliva, body fluids, and even
blood at times. Standard precautions One scoop: partial impression
must be observed while taking an 8. Add the measured powder to the water
impression of the mouth. in the bowl.
3. Make sure all equipment, especially the
bowl and spatula, are clean.
NOTE: Some dental offices use dispos-
able mixing bowls and spatulas. This
eliminates the need to disinfect or ster-
ilize the bowl and spatula after use.
4. Measure out the correct amount of
room-temperature (70°F or 21°C) water
using the manufacturer’s measuring
vial.
NOTE: Follow the manufacturer’s direc-
tions for the correct amount of water.
Usually, one measure of water is used
with one scoop or envelope of powder.
5. Place the water in the mixing bowl.
6. Fluff the powder in the container by FIGURE 18-56A Use the spatula to level the
rolling the container from side to side scoop of alginate powder.
PROCEDURE 18:10A
9. Use a circular motion to press the spat- require the use of an adhesive. Follow
ula against the side of the bowl and to manufacturer’s instructions provided
mix all of the powder with the water. with the impression trays.
10. Use a stropping (beating or pressing) 13. Fill the impression tray with the mix
action with the spatula to press the mix starting with the back of the tray and
against the side of the bowl (figure moving to the anterior portion of the
18-56B). Rotate the bowl as you mix. tray (figure 18-56D). Smooth the surface
This makes the mix creamy and smooth with a wet finger or wet spatula (figure
and removes air bubbles. 18-56E). Remove any excess material
from the back of the tray.
11. Mixing should be completed within 1
minute for regular-set and 30–45 sec- CAUTION: Regular-set alginate mix sets
onds for fast-set alginate. in 2–4 minutes, and fast-set alginate sets
in 1–2 minutes, so work quickly.
12. The impression tray can be sprayed with
a special lubricant spray before being
filled. This makes it easier to remove the
alginate at the end of the procedure (fig-
ure 18-56C). Some impression trays
FIGURE 18-56B Use a stropping action to

press the mix against the side of the bowl.
FIGURE 18-56D Place the alginate into the

tray starting with the back of the tray and
pushing the material to the front of the tray.
FIGURE 18-56C Before using the impression

tray, spray it with lubricant to make it easier to
remove the alginate material from the tray when FIGURE 18-56E Smooth the surface of the
the procedure is complete. alginate with a wet finger or spatula.
604 CHAPTER 18
PROCEDURE 18:10A
NOTE: Make sure the impression tray is CAUTION: Do not press too hard or the
the correct size. denture will go completely through the
alginate.
14. Hand the filled impression tray to the
doctor. Pass the tray handle first. The 17. Use steady pressure with the index fin-
doctor will insert the tray into the ger and the middle finger to hold the
patient’s mouth and hold the tray in denture in place (figure 18-57). Hold for
place until the alginate sets (figure 18- at least 1 minute.
56F).
18. After the alginate has set completely
NOTE: In some states, a dental assistant (usually in 2–4 minutes), check it for
may be allowed to take a preliminary smoothness. If it is smooth and does not
impression of a patient’s dentition. stick to your fingers, it is ready.
Check the legal requirements for your
19. Gently remove the denture from the
state.
alginate.
15. To take an impression from a denture,
NOTE: A very slight side-to-side motion
soak the denture in water first.
often releases the denture.
NOTE: This allows the denture to more
20. Use room-temperature tap water to
readily come out of the alginate.
gently rinse the impression for at least
CAUTION: Gloves should be worn while 30 seconds. Spray the impression with a
handling any denture to avoid contami- disinfecting solution to prevent con-
nation from saliva or fluids from the tamination from saliva, blood, or mouth
mouth. fluids that may be present on the impres-
sion.
16. Shake the excess water from the den-
ture. Place it in position on the alginate. 21. Pour the model as quickly as possible,
Press the anterior teeth of the denture preferably within 20 minutes. If you are
into place. Then press the back of the unable to immediately pour the model,
denture into position. wrap the alginate impression in a wet
paper towel. Place the towel-wrapped
impression in a plastic bag or covered
FIGURE 18-56F The impression tray must be

held in place in the patient’s mouth until the FIGURE 18-57 Use steady pressure to hold
alginate sets. the denture in the alginate.
PROCEDURE 18:10A
air-tight container to maintain 100 per- tions prior to using it on another
cent humidity. Soaking an impression patient.
in a bowl of water is not recommended.
Label the bag or container with the
patient’s name and date. 25. Remove all personal protective equip-
ment. Wash hands thoroughly.
CAUTION: The alginate will shrink
almost immediately if left to air-dry, and
this shrinkage leads to an inaccurate
model.
22. Clean the bowl and spatula. Place all
excess alginate in a trash container. Practice
Never pour alginate into the sink be- Go to the workbook and use the
cause it will clog the drain. The bowl and evaluation sheet for 18:10A,
spatula must be disinfected or steril- Preparing Alginate, to practice this
ized. Some offices use disposable bowls procedure. When you believe you have
and spatulas. These are discarded in an mastered this skill, sign the sheet and
infectious-waste container. give it to your instructor for further
23. To clean the impression tray, remove the action.
alginate. Discard all alginate in a trash
container. Use pipe cleaners to clean
out the holes in the tray. Scrub the tray
with a brush and place it in the ultra- Final Checkpoint Using the criteria
sonic unit for cleaning. Sterilize the tray listed on the evaluation sheet, your
according to manufacturer’s instruc- instructor will grade your performance.
PROCEDURE 18:10B
2. Wash hands. Put on disposable gloves, a
Preparing Rubber Base gown, face mask, and eye protection.
(Polysulfide) CAUTION: The mouth will contain
saliva, body fluids, and even blood at
Equipment and Supplies times. Standard precautions must be
observed while taking an impression of
Tubes of accelerator and base, rubber-base
the mouth.
materials, paper mixing pad (coated), metal
spatula, impression tray, adhesive, syringe, 3. Prepare tray and/or syringe, depending
tip, paper to make funnel, cleaning brush, on which will be used. Use heavy-bod-
disinfecting solution or spray, disposable ied rubber-base material for a tray and
gloves, gown, face mask, eye protection light-bodied rubber-base material for a
syringe.
Procedure a. To prepare the impression tray, apply
adhesive over the entire surface of
606 CHAPTER 18
PROCEDURE 18:10B
the tray if directed to do so by the
manufacturer. Allow the adhesive to
dry.
b. To prepare the syringe, put a plastic
tip on the end of the syringe (figure
18-58A). Make a paper funnel to
load the syringe: fold the paper in
half; then, fold a bias fold with one
end 1⁄4 inch and one end 1 inch (fig-
ure 18-58B).
4. Mark the mixing pad with the length of
strip desired (figure 18-58C). The FIGURE 18-58C Mark the mixing pad with
amount is determined by the impres- the length of strip desired.
sion to be taken.
5. Dispense an even line of accelerator
material. Close the cap on the tube
immediately.
NOTE: Strip of accelerator must be
smooth and even for correct propor-
tions.
6. Dispense a strip of base material that is
the same length as the accelerator. Close
the cap on the tube immediately.
NOTE: Strip will be wider in diameter,
but it is the same weight.
FIGURE 18-58A Put a plastic tip on the
syringe before mixing the rubber-base material. NOTE: Keep the materials separate (fig-
ure 18-58D). If either tube is contami-
nated by the contents of the other tube,
FIGURE 18-58B Fold a sheet of mixing-pad FIGURE 18-58D Keep the materials separate
paper to make a paper funnel to load the while dispensing equal strips of the accelerator
rubber-base syringe. and base.
PROCEDURE 18:10B
polymerization will occur and cause the in the area of the impression. The filled
entire contents of the tube to set or impression tray is then passed to the
harden. doctor for insertion into the patient’s
mouth.
7. Use accelerator material to coat both
sides of the metal spatula. Then push CAUTION: In many states, a dental
the accelerator material into the base assistant is not permitted to take a
material. rubber-base impression of a patient’s
dentition. The assistant’s role is to pre-
8. Mix the accelerator and the base. Use
pare the material for the doctor.
smooth strokes and broad sweeps. Mix
well until no strips or streaks of color are NOTE: Work quickly before the impres-
evident. sion sets. Curing time is usually 6–10
minutes.
NOTE: Mixing should be complete in
45–60 seconds. 11. After the impression tray is removed
from the mouth, rinse it in room-
9. Place the rubber-base mix in the pre-
temperature tap water for 30 seconds.
pared impression tray. If a syringe is to
Spray it with a disinfectant or soak it in a
be used, first place the material in the
disinfecting solution.
paper funnel. Then, roll the funnel and
squeeze the material into the syringe. CAUTION: The impression may be con-
Another way to fill the syringe with the taminated with saliva, blood, and mouth
rubber-base material is to remove the fluids. Observe standard precautions.
plastic tip and plunger. Use a repetitive
12. A model can now be poured. It is best to
stroking motion to push the end of the
pour a model as quickly as possible for
barrel into the material so that the mate-
the greatest degree of accuracy.
rial fills the inside of the syringe (figure
18-58E). Replace the plastic tip and 13. To clean the syringe, first squeeze out
plunger so the syringe is ready to use. excess material. Then, soak the syringe
in warm water for approximately 15
10. If a syringe is used, pass this to the doc-
minutes. Soak the impression tray after
tor first. The doctor uses the syringe to
the impression has been removed.
place the impression material directly
NOTE: Soaking allows the material to
set and makes it easy to peel off the tray,
spatula, or syringe.
14. Use a brush to remove any material left
on the spatula or tray or in the syringe.
Clean the syringe, spatula, and tray in
an ultrasonic unit. Follow manufactur-
er’s instructions to sterilize the syringe,
spatula, and tray.
NOTE: The syringe tips are disposable
and discarded after use. Disposable
impression trays are sometimes used
for rubber-base impressions.
FIGURE 18-58E The syringe can also be 15. Discard all excess rubber-base material
filled by pushing the end of the barrel into the and the mixing sheet in an infectious-
rubber-base material. waste container. Replace all equipment.
608 CHAPTER 18
PROCEDURE 18:10B
Check to be sure the caps are closed
tightly on both tubes of material.
16. Remove all personal protective equip-
ment. Wash hands thoroughly.
Practice
Preparing Rubber Base
(Polysulfide), to practice this
PROCEDURE 18:10C
Pouring a Plaster
Model
Alginate or rubber-base impression, mixing
bowl, hard spatula, plaster, metric graduate,
scale, vibrator, glass slab or tile square, water,
personal protective equipment (gloves, gown,
face mask, and eye protection)
Procedure
1. Assemble equipment (figure 18-59A).
2. Wash hands. Put on all personal protec- FIGURE 18-59A Equipment for pouring a
tive equipment (gloves, gown, face plaster model.
mask, and eye protection).
be room temperature (70°F or 21°C) or
CAUTION: Observe standard precau- cooler.
tions while working with an impres-
NOTE: Colder water allows more work-
sion.
ing time for beginners.
3. Prepare an alginate impression or use a
5. Pour the water into the bowl.
rubber-base impression a doctor has
prepared. Blot excess disinfecting solu- 6. Weigh the plaster powder. Use 100
tion from the impression. grams.
4. Measure the water (figure 18-59B). Use 7. Sift the powder into the bowl, allowing it
45–50 milliliters (mL). The water should to drop to the bottom of the bowl (figure
PROCEDURE 18:10C
10. Place the bowl on the vibrator platform.
Hold the bowl in place to remove air
bubbles from the mix (figure 18-59D).
11. Test the mix by holding the bowl upside
down. The mixture should not flow out
of the bowl. Cut through the mixture
with the spatula. The mix is the correct
consistency if it does not run back
together (figure 18-59E).
12. Place a plastic bag over the vibrator.
Place the impression on the covered
FIGURE 18-59B Measure 45 to 50 milliliters vibrator platform.
(mL) of water at 70°F (21°C) or cooler. NOTE: The plastic cover protects the
vibrator.
18-59C). Allow the powder to absorb all 13. Use the spatula to place a small amount
of the water. of plaster on the back, or heel, of the
impression (figure 18-59F). Vibrate the
8. With the spatula, use a wiping and tray lightly so the mix flows into the
scraping motion to mix the powder and impression, filling the “teeth.”
water.
CAUTION: Use only a small amount of
CAUTION: Avoid using a whipping plaster at a time to ensure even filling
motion because this creates air bub- and prevent air bubble formation.
bles.
14. Repeat step 13. Add the mix to the same
9. Scrape the mix against the side of the area each time. Try to keep the flow as
bowl to remove any lumps. even as possible. Repeat until the
impression is completely filled.
FIGURE 18-59D Use both hands to grasp

FIGURE 18-59C Allow the plaster to drop to the bowl of mix firmly on the vibrator platform to
the bottom of the bowl and absorb the water. remove air bubbles from the plaster.
610 CHAPTER 18
PROCEDURE 18:10C
15. Form the base of the model by placing
the remaining mix on a glass slab or tile
(figure 18-59G). The mix should be
approximately 1 inch thick.
16. Very carefully invert the entire impres-
sion and place it on the base. Do not
push down on the model.
NOTE: Use a damp paper towel to cre-
ate an arch on the mandibular model to
keep the plaster mix out of this area.
NOTE: In some dental settings, the
remaining mix is simply placed on top
of the model and built up to the correct
thickness. In other settings, a base for-
mer is used. It is filled with plaster to
form the base; the impression is then
inverted on top.
17. Smooth the mix on the sides of the
FIGURE 18-59E The consistency of the impression and base so the two areas
plaster mix is correct if the mix does not run join (figure 18-59H). The model should
back together after being cut with a spatula. be kept as level as possible.
18. Remove excess amounts of mix from the
sides and top of the model. Keep the
model basically smooth.
19. Put the model in a safe place. Allow it to
set. Do not disturb it for at least 1 hour.
NOTE: Setting time varies from 1–3
hours.
NOTE: The model will get hot. As heat is
produced, the water evaporates, and the
FIGURE 18-59F While holding the impres- FIGURE 18-59G Form the base of the model
sion tray on the vibrator platform, place a small by placing the rest of the plaster mix on a glass
amount of plaster mix on the back, or heel, of slab or tile. The impression is then inverted onto
the impression. this base.
PROCEDURE 18:10C
FIGURE 18-59H Smooth the mix on the

sides of the model to join the base to the model.
model sets (becomes solid). This is

FIGURE 18-59I Use a laboratory knife or
called an exothermic reaction.
spatula to remove dry plaster from the impres-
20. When the model is completely dry, sion tray before lifting the tray off the model.
remove it from the impression tray. Use
a laboratory knife or spatula to gently
scrape away any plaster material on the
impression tray (figure 18-59I). Use firm
but steady pressure to lift the tray away
from the model. Do not pull or twist the
tray from side to side because this may Practice
break the model, separate it from the Go to the workbook and use the
base, or break the teeth. evaluation sheet for 18:10C, Pouring
a Plaster Model, to practice this
21. Clean and replace all equipment. Place
all waste plaster in a trash container.
Use large amounts of water to flush the
sink. Scrub the bowls and other equip-
ment thoroughly. If the impression tray for further action.
is not disposable, it must be cleaned and
sterilized prior to being used for another
patient. Clean the counter top immedi-
ately.
22. Remove all personal protective equip- listed on the evaluation sheet, your
ment. Wash hands. instructor will grade your performance.
612 CHAPTER 18
PROCEDURE 18:10D
Pouring a Stone Model
Alginate or rubber-base impression, mixing
bowl, hard spatula, stone powder, metric
graduate and scale, vibrator, glass slab or tile,
water, personal protective equipment (gloves,
gown, face mask, and eye protection)
Procedure
2. Wash hands. Put on personal protective
equipment.
CAUTION: Observe standard precau-
tions while working with an impression.
FIGURE 18-60 A small scale is used to
3. Prepare an alginate impression or use a weigh the correct amount of stone material,
rubber-base impression a doctor has usually 100 grams.
prepared. Blot excess disinfecting solu-
tion from the impression. 11. Clean and replace all equipment. Place
excess stone in a trash container. Do not
4. Measure the water. Use 30 milliliters wash stone material down the sink drain
(mL) (following manufacturer’s instruc- because it will clog the plumbing. Scrub
tions). The water should be room tem- the bowl, spatula, and countertop thor-
perature (70°F or 21°C) or slightly cooler. oughly. Disinfect or sterilize the bowl
5. Pour the water into the bowl. and spatula. If they are disposable, place
them in an infectious-waste container.
6. Weigh the stone. Use 100 grams or fol-
low the manufacturer’s instructions (fig- 12. Remove personal protective equipment.
ure 18-60). Wash hands.
7. Sift the powder into the bowl. Allow the
powder to absorb the water.
NOTE: Place the bowl on the vibrator
platform for 5–10 seconds to aid mixing. Practice
8. Use a wiping and scraping motion to Go to the workbook and use the
mix the stone powder and water until a evaluation sheet for 18:10D,
uniform, creamy mixture is obtained. Pouring a Stone Model, to practice
CAUTION: Avoid using a whipping
motion, because this causes air bubbles.
9. Place the bowl on the vibrator platform. instructor for further action.
Hold the bowl firmly in place to remove
air bubbles from the mix.
10. To pour the model, follow steps 11–20 of Final Checkpoint Using the criteria
Procedure 18:10C, Pouring a Plaster listed on the evaluation sheet, your
Model. instructor will grade your performance.
PROCEDURE 18:10E
NOTE: A wet model is easier to trim and
Trimming a Model less likely to break.
4. Put on safety glasses.
5. Turn on the water supply to the model
Prepared model, model trimmer, bowl of trimmer. Turn on the model trimmer.
water, safety glasses Check to ascertain water is flowing freely
over the grinding wheel.
Procedure 6. Use light, even pressure to hold the
1. Assemble equipment. Study the dia- model and trim the base so it is smooth
gram in figure 18-61 to become familiar and even (figure 18-62A). The base
with the correct measurements for trim- should be parallel to the biting surfaces.
ming a model. It should be at least 1⁄2 inch thick and 1⁄3
the entire height of the model.
2. Wash hands.
CAUTION: Keep fingers away from the
3. Soak the model in a bowl of water for 5 wheel at all times. Use steady pressure
minutes. to hold the model.
7. Trim the back, or heel, of the model.
Approximately 1⁄4 inch should remain
behind the third molars. The heel should
be perpendicular to the base (figure
18-62B).
NOTE: If working on a set of models,
1/4"
first trim the mandibular model. Then,
Maxillary
hold the two models together so they
are in occlusion and fit together. Trim
1/4"
the maxillary model parallel to the
base of the mandibular model (figure
18-62C).
Heel 1/4"
1/2"
125°
Mandibular
Side 1/4"
Arc
FIGURE 18-62A Use light, even pressure to
FIGURE 18-61 Measurements for trimming a hold the model and trim the base so it is smooth
model. and even.
614 CHAPTER 18
PROCEDURE 18:10E
FIGURE 18-62D Draw a line from the center

of the central incisors to the cuspid to mark the
FIGURE 18-62B Trim the back, or heel, of anterior cut.
the model so it is perpendicular to the base.
mandibular model, mark the cuspids
and make an arc cut.
11. Label the model(s) with the patient’s
name and the date. Recheck both the
maxillary and mandibular model to
make sure they are trimmed correctly
(refer to figure 18-53).
12. Clean the trimmer thoroughly. Use a
brush to clean the wheel. Remove the
platform to wash and dry the inside of
the trimmer.
13. Use large amounts of water to rinse the
sink drain.
FIGURE 18-62C Hold the two models 14. Replace all equipment.
together in occlusion to align the heel cuts.
15. Wash hands.
8. Trim the sides of the model. On the max-
illary model, form a 63-degree angle
with the heel. Cut to within 1⁄4 to 3⁄8 inch
of the bicuspids (refer to figure 18-61). Practice
On the mandibular model, form a 55- Go to the workbook and use the
degree angle with the heel. Cut to within evaluation sheet for 18:10E,
1
⁄4 to 3⁄8 inch of the bicuspids. Trimming a Model, to practice this
9. Trim the heel points to approximately 1⁄2 procedure. When you believe you
inch in length and to form a 125-degree have mastered this skill, sign the
angle with the heel. sheet and give it to your instructor
for further action.
10. On the maxillary model, draw a line
from the center of the central incisors to
the cuspids (figure 18-62D). Make two Final Checkpoint Using the criteria
cuts, one on each side, to form a point listed on the evaluation sheet, your
between the two central incisors. On the instructor will grade your performance.
18:11 INFORMATION
Making Custom Trays
Making custom trays for impressions may be one
of the responsibilities of the dental assistant.
Custom trays are impression trays made to fit a
particular patient’s mouth. To obtain exact
impressions, a tray must be exactly fitted to the
patient’s mouth. Thus, a custom tray is pro-
duced.
To make a custom tray, the first step is to
make a model or cast of the patient’s mouth from
a standard impression tray. Then an impression
is taken, and a stone or plaster model is poured.
This is often referred to as a preliminary impres-
sion. The stone or plaster model of the patient’s
mouth is then used as a base to form the custom
tray. In this way, the tray is fitted perfectly for the
individual. The tray can then be used with a vari-
ety of impression materials to get an exact impres-
sion of the patient’s mouth.
FIGURE 18-63A The heating element of the
vacuum-form unit softens the acrylic sheets so they
Various materials are used to make custom
droop down from the tray.
trays. Acrylic resins are the most popular because
they produce a stronger tray that can be used position over the model (figure 18-63B). Vacuum
with all types of impression materials. The acrylic pressure is used to shape the resin sheets to
resins are supplied as a liquid catalyst and a pow- the model to form the custom tray. After the
der that are mixed together. A process known as material has cooled, the tray can be separated
curing (polymerization) causes the material to from the model and trimmed with scissors (fig-
become pliable so it can be fitted to the contour ure 18-63C).
of the preliminary model. As curing continues,
an exothermic reaction occurs in which the mate-
rial gives off heat and becomes rigid or hard.
Acrylic resins can be self-curing or light-curing.
The light-cured resins do not set or become hard
until they are exposed to a light in a special cur-
ing oven.
Because acrylic resins are difficult to remove
from mixing jars or containers, a plastic- or wax-
lined disposable paper cup and tongue blades
are used to mix the material. Coating the fingers
lightly with petroleum jelly helps prevent the
material from sticking to the hands.
Acrylic resins are also supplied as sheets that
can be vacuum formed. A vacuum-form unit with
a heating element is used to make this type of
custom tray. The preliminary model is placed on
the platform of the unit. Acrylic resin sheets are
positioned in a frame located under the heater at
the top of the unit. As the unit heats the acrylic FIGURE 18-63B When the acrylic sheets drop 1
sheets, they begin to droop down from the frame inch below the frame, the frame is positioned over
(figure 18-63A). When the sheets are 1 inch below the model. Vacuum pressure is then used to mold
the holding frame, the frame is dropped into the custom tray.
616 CHAPTER 18
Custom trays must be labeled with the

patient’s name and used exclusively for that
patient. Most manufacturers of acrylic resins sug-
gest allowing the material to set for 24 hours
before use to be sure it is completely stable. Any
of the impression materials can be used in the
tray to get an exact impression of the patient’s
mouth.

the assignment sheet for 18:11, Making Custom
FIGURE 18-63C After it has cooled, the vacuum- Trays. Then return and continue with the proce-
formed custom tray can be trimmed with scissors.
dure.
PROCEDURE 18:11
Making Custom Trays
Powder and liquid catalyst tray materials,
measuring devices, paper cups and tongue
blades, petroleum jelly, glass slab, baseplate
wax, alcohol lamp or bunsen burner, wax
knife, acrylic bur or stone, plaster or stone
model, safety glasses, gloves
Procedure
3. Use a single layer of baseplate wax to
cover the teeth and other specified areas
of the model (figure 18-64A). This serves
as a spacer for the tray. Cover the wax
spacer with aluminum foil or coat it with FIGURE 18-64A Use baseplate wax to cover
the teeth of the model and form a spacer.
a separating liquid.
CAUTION: Never use a rubber bowl for
NOTE: Use warm water to warm the wax
mixing. Paper cups provide for easier
to make it more pliable.
cleanup because they can be discarded.
NOTE: Special rolls of liner material are
5. Use a tongue blade for mixing. Mix thor-
also available to cover the teeth. The
oughly for approximately 1 minute until
liner material is cut to size, moistened,
the mix is uniform.
and then placed over the teeth.
6. Allow the mixture to stand until it is not
4. Pour the required amount of liquid (fol-
sticky to the touch and is stringy when
low manufacturer’s instructions) into a
pulled, approximately 2–3 minutes.
paper cup. A wax- or plastic-lined paper
cup is preferred. Measure the correct 7. Coat the model, glass slab, and your
amount of powder and add it to the liq- hands with petroleum jelly to prevent
uid in the cup. the material from sticking.
PROCEDURE 18:11
8. Remove the mixture from the cup and
knead it gently (figure 18-64B).
9. Place the material on the glass slab. Roll
or form it into a wafer with a uniform
thickness of approximately 1⁄16 to 1⁄8 inch.
10. Remove the wafer from the tray. Slowly
adapt it to the model. Start at the palate
area and extend to the sides (figure
18-64C).
11. Form a handle on the tray. Extra mate-
rial can be applied by using a small
amount of the resin liquid at the point FIGURE 18-64C Start at the palate area to
of attachment. adapt the wafer of custom tray material to the
12. Use a knife to remove excess material model.
from the sides.
13. Allow the tray to cure for 7–10 minutes.
Then, gently remove the tray from the
model.
14. Remove the aluminum foil and wax
spacer, unless the doctor wants it left in
place. Label the tray with patient’s name.
15. Use special acrylic burs or an arbor band
on a lathe to trim and smooth the tray
(figure 18-64D).
CAUTION: Wear safety glasses while
trimming the tray.
16. Clean and replace all equipment. The
liquid catalyst can be used to remove FIGURE 18-64D An acrylic bur can be used
mix from surfaces, but it should be used to trim and smooth the edges of a custom tray.
sparingly.
17. Wash hands.
Practice
evaluation sheet for 18:11, Making
Custom Trays, to practice this
for further action.
FIGURE 18-64B When the mixture is not Final Checkpoint Using the criteria
sticky to the touch, remove the material from the listed on the evaluation sheet, your
cup and knead it gently. instructor will grade your performance.
618 CHAPTER 18
There are two main kinds of injections used

18:12 INFORMATION to produce local anesthesia in the oral cavity (fig-
ure 18-65):
Maintaining and Loading an
Anesthetic Aspirating Syringe ♦ Block: The anesthetic is injected near a main
nerve trunk. This kind of injection is used pri-
Anesthesia is used in many dental proce- marily for mandibular teeth. Several teeth are
dures to decrease pain or discomfort. Some anesthetized.
responsibilities of the dental assistant with regard
to anesthesia are discussed in this section. It is
♦ Infiltration, or field: The anesthetic is injected
around the terminal nerve branches of the
important to note, however, that the degree of
teeth. This kind of injection is used mainly for
responsibility may vary from state to state.
maxillary teeth, but it can be used for anterior
Pain control is an important part of any den-
mandibular teeth. Each tooth usually requires
tal procedure. Anesthesia, which means
a separate injection.
“absence of feeling,” is the term used to describe
the condition that exists when the sensation of A variety of medications are used to produce
feeling pain has been decreased or eliminated. local anesthesia. The main local/anesthetic
The type of anesthesia used depends on the needs medication is lidocaine (Xylocaine). It decreases
of the patient. Different types of anesthesia nerve sensation. Other anesthetics that may be
include:
♦ General anesthesia: This type renders the

patient unconscious. It is usually used in a
hospital and administered by an anesthesiolo-
gist. It is seldom used in dental offices.
♦ Analgesia or sedation: This type causes loss of
ability to feel pain but not loss of conscious-
ness. In dental offices, analgesia is usually
given by having the patient inhale a mixture of
nitrous oxide and oxygen gases. This causes
the patient to feel pleasantly relaxed but
remain awake and able to cooperate. The
effects wear off very quickly after the adminis-
tration is stopped. Other forms of sedation are
also used. These include oral doses or injec-
tions of mild sedatives, or tranquilizers.
♦ Local anesthesia: This is the form of anesthe-
sia used most frequently in dental offices. An
A
anesthetic is injected into the area where loss
of sensation is desired. This decreases or elim-
inates the sensation of pain in the specific
area but has no effect on the patient’s level of
consciousness.
♦ Topical anesthesia: Topical anesthetics are fre-
quently used to reduce the pain or discomfort
caused by the injection for local anesthesia.
These anesthetics are applied to the mucous
membrane to desensitize the area where
another anesthetic is to be injected. Topical
anesthetics are available as liquids, sprays, B
gels, and ointments. In some states, the dental FIGURE 18-65 Types of injections for dental
assistant is allowed to apply the topical anes- anesthesia: (A) maxillary infiltration and (B) man-
thetic. dibular block.
used include mepivacaine, or Carbocaine, and (2) An extruded plunger with no air bubble
prilocaine, or Citanest. Procaine, or Novocain, is usually means that the cartridge was left
used infrequently. Vasoconstrictors are often in a disinfecting solution too long. The
added to anesthetics. Vasoconstrictors decrease disinfecting solution passed through the
the size of the blood vessels in the area and, thus, rubber diaphragm and entered the car-
keep the blood from rapidly carrying away the pule. Do not use.
anesthetic. In this way, the anesthesia effect is
prolonged. Vasoconstrictors also help reduce
♦ Check the bubbles: Small bubbles (1–2 mm)
are normal. Large bubbles are usually caused
bleeding at the site. Epinephrine is a common
by freezing. Return a carpule containing large
vasoconstrictor.
bubbles to the supplier for replacement.
CAUTION: Vasoconstrictors can be danger-
ous for patients with heart disease, hyper- ♦ Check the aluminum cap: A thin diaphragm is
thyroidism, and hypertension (high blood in the center of the cap to allow for the inser-
pressure). It is important to review the patient’s tion of the needle. Rust from the container can
health history and follow the doctor’s directions contaminate the caps. It is best not to use a
before epinephrine is used. carpule having rust on the cap.
Anesthetic carpules (cartridges) are glass ♦ Care of carpules: Do not autoclave carpules.
cylinders that contain premeasured amounts of They are sterile on the inside. It is best not to
anesthetic solutions (figure 18-66). The carpule soak any carpule for a long time because the
fits into the barrel of a syringe. This is the most disinfecting solution can pass into the rubber
common delivery system for local-anesthetic diaphragm and contaminate the solution
injection. The following points must be observed inside. Prior to using any carpule, use a sterile
when using carpules: pad moistened with 70-percent ethyl alcohol
♦ Check the glass: Do not use if cracks or chips or 91-percent isopropyl alcohol to rub the alu-
are present. minum cap end and rubber-plunger end. Car-
tridge dispensers are available for conveniently
♦ Check the solution: It should be clear in color. storing carpules (figure 18-67).
If it is yellow or straw colored, this may mean
that the epinephrine has broken down. Do not Aspirating syringes are commonly used to
use a carpule containing discolored solution. inject local anesthetic. Aspiration means “draw-
ing back by suction.” After penetrating the
♦ Check the rubber plunger: It should be level
mucous membrane with the syringe, the doctor
with or just slightly below the top of the car-
draws back on the syringe to be sure the needle
tridge.
has not penetrated a blood vessel and to be sure
(1) An extruded (pushed-out) plunger with a
it is properly inserted in the tissues before inject-
large air bubble usually means that the
ing the medication.
cartridge was frozen. Do not use.
B C
E
FIGURE 18-66 Parts of an anesthetic carpule

(cartridge): (A) rubber diaphragm, (B) aluminum
cap, (C) neck, (D) glass cylinder, and (E) rubber FIGURE 18-67 Cartridge dispensers are used to
plunger or stopper. store the carpules conveniently.
620 CHAPTER 18
FIGURE 18-68 Parts of the aspirating syringe: (A) needle adaptor, (B) barrel, (C) guide bearing, (D) spring,
(E) piston with harpoon, (F) finger grip, and (G) thumb ring.
Parts of the anesthetic aspirating syringe are ♦ Thumb ring: area of insertion for the thumb to
shown in figure 18-68 and include: allow for aspiration and injection
♦ Needle adaptor: threaded area at the end of After each use, the syringe must be washed
the syringe where a disposable needle is thoroughly and rinsed. It must then be auto-
attached to the syringe claved. After each five uses, the syringe should be
♦ Barrel: cylinder with one open side to allow for dismantled, or taken apart. All parts should be
the insertion of the anesthetic carpule (car- checked carefully. Worn or defective parts should
tridge) be replaced. Threaded areas should be lubri-
cated.
♦ Guide bearing: stabilizes the movement of the Standard precautions must be followed
piston and harpoon
while handling the disposable needle after
♦ Spring: allows for the advancement and retrac- an injection has been given. Handle the needle
tion of the piston and harpoon carefully to avoid needle sticks. The needle must
♦ Piston with harpoon: a metal shaft with a be removed from the syringe and placed in a leak-
barbed tip to allow the harpoon to be inserted proof puncture-resistant sharps box. It must not
in the rubber plunger of the carpule be bent, broken, or recapped. If the needle must
be recapped during the procedure, a one-handed
♦ Finger grip: supports the index and middle scoop technique must be used. The needle guard
fingers as the anesthetic solution is being or cover must be placed on a tray or in a special
injected into the tissues recap device designed to hold the guard in posi-
tion (figure 18-69A–C). The used needle should
FIGURE 18-69B The needle guard is clamped

FIGURE 18-69A This recap device has its own into the recap device. The used needle is then
sharps container to dispose of the used needle and placed in the needle guard. (Courtesy of Patrick
guard. (Courtesy of Patrick Reineck, DDS) Reineck, DDS)
then be inserted into the guard or cap. Fingers

must be kept off of the guard until the end of the
needle is covered. Once the needle end is covered
by the guard or cap, it is safe to pick up the guard
and slip it firmly into position over the needle.
Correct care of carpules and syringes, and
correct loading of syringes are part of the respon-
sibilities of a dental assistant. Procedures 18:12A
and 18:12B provide additional information.
FIGURE 18-69C The syringe is separated from STUDENT: Go to the workbook and complete
the needle. Then the clamp on the recap device is the assignment sheet for 18:12, Maintaining and
released to allow the used needle and guard to drop Loading an Anesthetic Aspirating Syringe. Then
into the sharps container. (Courtesy of Patrick return and continue with the procedures.
Reineck, DDS)
PROCEDURE 18:12A
NOTE: Parts may vary slightly depend-
Maintaining an ing on the manufacturer.
Anesthetic Aspirating 5. Use soap and water to clean all parts
Syringe thoroughly. Rinse all parts.
6. Inspect the piston and harpoon. Make
Equipment and Supplies sure the harpoon is sharp and not dam-
aged.
Soap, water, aspirating syringe, pliers, lubri-
cation, personal protective equipment 7. Check the needle adaptor. Make sure
(gloves, gown, face mask, and eye protec- the hole is open and not plugged.
tion) 8. Check all other parts. Make sure they
are not damaged or defective.
Procedure NOTE: Parts can be replaced. This is
1. Assemble equipment. more economical than replacing the
entire syringe.
equipment. 9. Lubricate all of the threaded joints:
thumb ring, piston top, barrel, and
CAUTION: Observe standard precau- adaptor.
tions while working with a contami-
nated aspirating syringe. 10. Put the syringe back together. First, put
the needle adaptor on the barrel. Then,
3. Use pliers and gentle pressure to place the guide bearing narrow end
unscrew the parts of the syringe. down on the piston. Next, place the
4. Use the manufacturer’s instructions to spring on top. Screw on the finger grip
identify all of the following parts: and thumb ring. Finally, place on the
• thumb ring barrel and secure.
• finger grip 11. Check the syringe to make sure it is
• spring secure and correctly assembled.
• guide bearing
• piston with harpoon 12. After each use, wash the syringe thor-
• barrel oughly. Rinse and dry the syringe. Steril-
• needle adaptor ize it in the autoclave.
622 CHAPTER 18
PROCEDURE 18:12A
13. After each five uses, repeat steps 1–11 of
this procedure to check the anesthetic
aspirating syringe and keep it in good
condition. Replace any defective parts. Practice
Then, sterilize by autoclaving prior to Go to the workbook and use the
use. evaluation sheet for 18:12A,
Maintaining an Anesthetic
14. Replace all equipment. Aspirating Syringe, to practice this
15. Remove personal protective equipment. procedure. When you believe you
Wash hands thoroughly. have mastered this skill, sign the
Final Checkpoint Using the criteria for further action.
PROCEDURE 18:12B
Loading an Anesthetic tions while working with an aspirating
Aspirating Syringe syringe.
3. Check the carpule. Note color of solu-
Equipment and Supplies tion, location of plunger, condition of
aluminum cap, presence of bubbles,
Aspirating syringe, needles, carpules, car-
and condition of glass. Use gauze con-
tridge dispenser, gauze with disinfectant
taining 70-percent ethyl alcohol or 91-
solution, sharps container, personal protec-
percent isopropyl alcohol to wipe the
tive equipment (gloves, gown, face mask, and
rubber diaphragm on the aluminum
eye protection)
cap end and the plunger end of the car-
pule.
Procedure
CAUTION: Never use a defective car-
1. Assemble equipment (figure 18-70A). pule. Discard or return it to the sup-
Check with the doctor to determine the plier.
type of cartridge and needle length and 4. Check the syringe. Note condition of the
gauge to use. harpoon and other parts.
CAUTION: The doctor will determine 5. Place fingers and thumb on the thumb
the type of medication after checking ring and finger grip. Retract the piston
the patient’s medical history. If the all the way back.
patient has allergies, hyperthyroidism,
heart disease, or hypertension, epi- 6. Place the carpule in the syringe, with
nephrine (a vasoconstrictor) is usually the plunger end going into the harpoon
not used. end first (figure 18-70B). The aluminum-
cap end will then fall into place.
equipment.
PROCEDURE 18:12B
FIGURE 18-70A Equipment and supplies for FIGURE 18-70C Use moderate pressure on
loading an anesthetic aspirating syringe. the thumb ring to engage the harpoon into the
rubber plunger.
FIGURE 18-70D Attach the needle to the

needle adaptor by screwing it in place.
center of the rubber diaphragm on the

FIGURE 18-70B Place the plunger end of the cap of the carpule.
cartridge into the barrel first, and the aluminum NOTE: Size (gauge and length) of the
cap end will then fall into place. needle used will be determined by the
doctor.
CAUTION: Never force the carpule into NOTE: The needle can be attached
place; it will break. before the harpoon is engaged in the
rubber plunger.
7. Engage the harpoon into the rubber
plunger. Use moderate pressure on the CAUTION: Always leave the cover on
thumb ring to push the piston forward the needle end to prevent contamina-
until the harpoon is firmly engaged in tion and accidental needlestick inju-
the plunger (figure 18-70C). Make sure ries.
not to push too far.
9. Prior to administration of the injection,
8. Attach the needle to the needle adaptor remove the protective cap from the nee-
by screwing it in place (figure 18-70D). dle. Expel a few drops of the solution to
Make sure the needle is engaged in the make sure the eye of the needle is open.
624 CHAPTER 18
PROCEDURE 18:12B
10. Expel all air bubbles from the carpule. touching the cap. When the needle end
Using extreme caution, replace the pro- is covered by the cap, push the cap
tective cap on the needle loosely so it firmly in place over the needle. At the
can be easily removed. end of the procedure, remove the needle
with the cap in place from the syringe
11. When the doctor is ready for the anes-
and discard the needle and cap in a
thesic, first pass a gauze sponge to dry
sharps container.
the injection area. Then, pass topical
anesthetic as needed. Position the nee- 13. Record the type and amount of local
dle with the beveled side toward the anesthetic used on the patient’s chart.
patient’s teeth. Direct the entire syringe
14. Care for the syringe as instructed in Pro-
toward the path of insertion. Use a
cedure 18:12A. Place the empty carpule
palm-grasp position to place the syringe
in a sharps container.
in the doctor’s hand. As the doctor
grasps the syringe, carefully remove the 15. Replace all equipment.
protective cap from the needle. Some 16. Remove personal protective equipment.
doctors prefer to remove the cap with a Wash hands thoroughly.
recap device.
NOTE: Keep the syringe out of the
patient’s sight by passing it at the
patient’s chin level or below.
12. To unload the syringe, carefully unscrew
the needle and place it in a sharps con-
Practice
tainer. Then, use one hand to hold the evaluation sheet for 18:12B,
carpule in position and use the other Loading an Anesthetic Aspirating
hand to disengage the harpoon. Invert Syringe, to practice this procedure.
the syringe so that the carpule falls out.
Keep the piston retracted.
CAUTION: Never recap the needle by and give it to your instructor for
hand after use. If it must be recapped to further action.
protect the doctor or the dental assis-
tant, use a one-handed scoop tech-
nique. Put the needle cap, cover, or
guard on a tray or in a special recap Final Checkpoint Using the criteria
device that holds the cover securely. listed on the evaluation sheet, your
Insert the needle into the cap without instructor will grade your performance.
18:13 INFORMATION ♦ Liner: Material used to cover, line, or seal

exposed tooth tissue, such as dentin. It is usu-
Mixing Dental Cements ally in the form of a varnish.
and Bases ♦ Base: Protective material that is placed over
Cements and bases are used in a variety of dental the pulpal area of a tooth to reduce irritation
procedures. They are used to line or prepare a and thermal (heat) shock. Used under large
tooth for a restoration and/or as luting agents to restorations.
cause materials to stick together. Important ter- ♦ Cement: Material used to permanently seal
minology includes the following: inlays, orthodontic appliances, crowns, and
bridges in place. It is sometimes used as a inlays, crowns, and bridges. Tenacin and
temporary filling or as a base for restorations Fleck’s are two examples of brand names.
when sedation is necessary. ♦ Polycarboxylate is also called zinc polyacrylate
♦ Temporary: Material used as a restorative or carboxylate. It is used as a cement for orth-
material for a short time and only until per- odontic bands and brackets, crowns, and
manent restoration can be done. bridges, and as a base under some restora-
tions. Some brand names include Durelon,
A large variety of products are available. Some
Hybond, and Tylock-Plus.
products have several uses and can act as a base,
cement, or temporary, depending on the need. Correct mixing techniques must be followed
Always read manufacturer’s directions for mixing when using bases or cements. Amounts must be
and use. Some of the types available are as measured carefully. Mixing times and proper
follows: manipulation techniques must be followed.
Improper mixing techniques can lead to a poor
♦ Varnish acts as a liner to protect exposed sur- base or cement and shorten the life of the resto-
faces of dentin from thermal shock and irrita- ration that is placed on top. Read the instructions
tion. It is placed under a restoration. If the carefully for each type.
varnish contains an organic solvent such as Cements and bases are available in many dif-
ether, acetone, or chloroform, it cannot be ferent forms. Sometimes, a liquid and paste are
used under composite restorations because it used. Other times, liquids and powders or two
interferes with the setting of the restoration. pastes are used. In most cases, care must be taken
Many brands of varnish are available, includ- to avoid mixing the substances in their contain-
ing Copal, Copalite, Varnal, and Handi-Liner. ers because a small amount of liquid added to a
♦ Zinc oxide eugenol (ZOE) has a sedative powder in a container can ruin or destroy the
effect when placed under a restoration. entire contents of the container. Therefore, it is
When it is reinforced with other substances, important to follow precautions that prevent
ZOE is also used as a base under metallic res- mixing the containers of material together and to
torations or as a temporary cement or restora- use clean measuring devices.
tion. It is not recommended as a base material Some brands of cements and bases require
for resins or composites (anterior restorations) light curing. A visible light source is held close to
because it interferes with the setting reaction the preparation for a brief time, usually about 20
of these materials. Some brand names for ZOE seconds for each 1-millimeter layer. This causes
are I.R.M., Cavitec, Wonder Pak, and Interval. the material to “cure” or set and become hard.
Light shields must be used by the dentist, the
♦ Calcium hydroxide is used as a base in larger patient, and assistant to prevent eye irritation
restorations and for pulp capping. It stimu-
from the visible light source.
lates the formation of secondary dentin to
Procedures for mixing some types of cements
protect the pulp. Because it is water soluble,
and bases are described on the following pages.
calcium hydroxide is not used for temporary
These procedures provide a basic introduction.
restorations. Some brand names include
Dycal, Preline, Hypocal, and Dropsin.
♦ Zinc phosphate is used as a thermally protec- the assignment sheet for 18:13, Mixing Dental
tive base under metallic fillings and as a Cements and Bases. Then return and continue
cement to retain gold restorations such as with the procedures.
626 CHAPTER 18
PROCEDURE 18:13A
4. When the doctor has completed the
Preparing Varnish cavity preparation, pass the air-water,
or tri-flow, syringe to the doctor. The
Equipment and Supplies cavity preparation must be dry before
varnish is applied.
Cavity varnish, varnish solvent or thinner,
cotton pliers, cotton pellets, special applica- 5. Put two cotton pellets in the cotton pli-
tors (with some products), air syringe, per- ers. Dip the pellets into the varnish to
sonal protective equipment (gloves, gown, saturate them (figure 18-71B). Remove
face mask, and eye protection) the excess varnish by placing both pel-
lets on a 2 ⫻ 2 gauze pad. Pick up one
NOTE: Copal, Copalite, Varnal, and Handi- saturated cotton pellet with the cotton
Liner are brand names of varnish. pliers and pass it to the doctor.
Procedure NOTE: Two pellets are saturated at the

same time to avoid contamination of
1. Assemble equipment. Read and follow the varnish with the cotton pliers. To
the manufacturer’s instructions for the prepare the pellets one at a time, two
specific varnish being used. pairs of cotton pliers must be used.
2. Wash hands. Put on personal protective NOTE: Special applicators are some-
equipment. times used. Cotton fibers are placed on
the end of the applicator, and the appli-
CAUTION: Observe standard precau- cator is then dipped in the varnish. A
tions while assisting with any dental second applicator must be used for the
procedure. second pellet.
3. Check the bottle of varnish. If the con- 6. The doctor paints the dentin surface
tents are too thick, add thinner if with the varnish. The dental assistant
directed to do so by the manufacturer should be ready to receive the pliers.
(figure 18-71A). Loosen caps slightly,
but leave in place until ready for use. 7. Pass the air syringe to the doctor. The
area is dried with warm air for approxi-
NOTE: Evaporation occurs if caps are mately 15–30 seconds.
left off bottles.
FIGURE 18-71A Some types of varnish must FIGURE 18-71B Cotton pliers can be used to
be thinned with a thinner solution when they hold the cotton pellet while saturating the pellet
become thick. with varnish.
PROCEDURE 18:13A
8. Discard the used cotton pellet. Pick up also be used to clean varnish from the
the second saturated cotton pellet with enamel of the tooth being prepared.
the cotton pliers. Pass the pliers to the
12. Clean and replace all equipment. Scrub
doctor.
and sterilize all instruments.
9. The doctor will apply a second coat of
13. Remove personal protective equipment.
varnish. Very porous teeth sometimes
Wash hands thoroughly.
require three applications. If a third coat
is necessary, use clean, uncontaminated
cotton pliers to saturate a new cotton
pellet with varnish.
NOTE: Varnish acts as a liner and sealer.
It protects against thermal shock and
Practice
protects the dentin from acids in the
restoration materials.
Preparing Varnish, to practice this
10. When you receive the pliers, discard the procedure. When you believe you
pellet. Close the lid on the varnish bottle have mastered this skill, sign the
immediately to avoid evaporation. sheet and give it to your instructor
NOTE: The thinner can be used to clean for further action.
the screw threads on the top of the var-
nish bottle. This helps prevent the lid
from sticking on the varnish bottle.
11. Thinner can be used as a solvent to listed on the evaluation sheet, your
clean varnish from instruments. It can instructor will grade your performance.
PROCEDURE 18:13B
Preparing Calcium equipment.
Hydroxide CAUTION: Observe standard precau-
tions while assisting with any dental
Equipment and Supplies procedure.
Base, catalyst, ball-pointed mixing instru- 3. Place equal small dots of the base and
ment, mixing pad, personal protective equip- the catalyst on the mixing pad side by
ment (gloves, gown, face mask, and eye side. Close the caps on the tubes imme-
protection) diately after dispensing the material.
NOTE: Brand names for calcium hydroxide CAUTION: Take care that neither sub-
include Dycal, Preline, Hypocal, and Dropsin. stance contaminates the tube of the
This procedure is for Dycal. other substance. If the catalyst mix
enters the base tube, it can destroy the
Procedure base material.
4. When the doctor is ready for the base,
1. Assemble equipment. Read and follow use the ball-pointed mixing instrument
the manufacturer’s instructions for the to mix the two pastes together (figure
brand being used.
628 CHAPTER 18
PROCEDURE 18:13B
18-72). The mix should be uniform in important to work quickly and effi-
color. Mixing should be completed in 10 ciently.
seconds.
NOTE: Some brands of calcium hydrox-
5. Immediately place a small amount of ide are light-cured. A visible light source
the mix on the end of the mixing instru- is used to cure or set these materials.
ment. Pass the mixing instrument to the
7. Hand instruments to the doctor to
doctor.
remove excess material.
NOTE: Calcium hydroxide is used as a
8. Clean and replace all equipment. A 10-
base under restorations. It serves as a
percent sodium hydroxide solution or
protective barrier between the dentin
orange solvent can be used to remove
and pulp and between cements and
the calcium hydroxide from instru-
restorative materials. Because it is water
ments. Instruments must then be
soluble, it cannot be used as a tempo-
scrubbed and sterilized. Check to be
rary filling material.
sure the caps are secure on both tubes.
6. Reapply the mix to the mixing instru- Clean the outsides of the tubes, if neces-
ment until the doctor has used the sary. Tear the used sheet off of the mix-
required amount of base. The mixing ing pad and discard the sheet in a waste
pad of material can also be held near container.
the patient’s chin so that the doctor can
obtain mix as needed.
NOTE: Calcium hydroxide sets in
approximately 21⁄2 to 3 minutes. In the
mouth, it sets faster because of moisture
and mouth temperature. Therefore, it is
Practice
Preparing Calcium Hydroxide, to

FIGURE 18-72 A ball-pointed instrument can listed on the evaluation sheet, your
be used to mix the base and catalyst together. instructor will grade your performance.
PROCEDURE 18:13C
turer’s recommendations for amount.
Preparing Sample measurements are as follows:
Polycarboxylate a. Cement: Use three drops of liquid for
one scoop of powder.
Equipment and Supplies b. Base: Use two drops of liquid for one
Powder, scoop, liquid, mixing pad or glass scoop of powder.
slab, flexible stainless steel or plastic spatula,
NOTE: Some manufacturers provide
personal protective equipment (gloves, gown,
calibrated, syringe-type liquid dispens-
face mask, and eye protection)
ers (figure 18-73A). Follow instructions
NOTE: Durelon, Hybond, and Tylock-Plus are to use this type of dispenser. Usually,
brands of polycarboxylate. They are used as a the plunger is moved from one full cali-
cement and as a base under restorations. This bration to the next calibration to obtain
procedure is written for Durelon. each drop of liquid required. If two
drops of liquid are needed, the plunger
Procedure would be moved through two calibra-
tions on the syringe.
1. Assemble equipment. Read and follow 7. Use the spatula to add all of the powder
the manufacturer’s instructions for the to the liquid at one time. Mix vigorously.
brand being used. The mix should be completed in 30 sec-
2. Wash hands. Put on personal protective onds. The final mix should appear
equipment. glossy.
CAUTION: Observe standard precau- CAUTION: Do not start mixing until the
tions while assisting with any dental doctor is ready. Dispense the liquid only
procedure. when you are ready to use it.
3. With the lid in place, fluff the powder by
gently inverting the container several
times. Open the lid carefully to avoid
inhaling the powder.
4. Press the measuring scoop down into
the powder. Use firm pressure to fill the
scoop. Withdraw the scoop. Use the
spatula to remove excess powder from
the outside of the scoop. Use the spatula
to level the powder.
5. Invert the scoop over the mixing pad (or
glass slab). Tap the side with the spatula
to release all of the powder.
NOTE: If a glass slab is used, first cool it
by placing it under cold, running water.
Dry it thoroughly.
6. Hold the bottle of liquid in a vertical FIGURE 18-73A Some polycarboxylates use
position. Squeeze the required number calibrated syringe dispensers for the liquid.
of drops of liquid onto the pad and (Courtesy of 3M-ESPE Dental Products
beside the powder. Follow the manufac- Division)
630 CHAPTER 18
PROCEDURE 18:13C
8. The final mix should be used while it is after use. If the material has set, a 10-
glossy. If the mix loses its shine or percent sodium hydroxide solution or
becomes stringy, it has started to set and orange solvent can be used to clean the
should not be used (figure 18-73B). The instruments.
doctor has approximately 2–3 minutes
11. Clean and replace all equipment. Wash
of manipulation time, so it is important
all instruments thoroughly and then
to work quickly and efficiently.
sterilize them correctly. Tear the used
9. Close the lid on the bottles of liquid and sheet off of the mixing pad and discard
powder immediately after use. The the sheet in a waste container.
opening of the dropper bottle must be
kept clean.
10. Use water to wipe the mixing spatula
and instruments clean immediately
Practice
Preparing Polycarboxylate, to
FIGURE 18-73B If the polycarboxylate mix Final Checkpoint Using the criteria
loses its shine or becomes stringy, it has started listed on the evaluation sheet, your
to set and should not be used. instructor will grade your performance.
PROCEDURE 18:13D
val. This procedure is written for I.R.M.
Preparing Zinc Oxide It is used as a base under amalgam res-
Eugenol (ZOE) torations and as a temporary cement or
restoration. It cannot be used under
Equipment and Supplies resin or composite restorations.
Containers of powder and liquid, mixing pad, Procedure

small spatula, measuring devices, personal
protective equipment (gloves, gown, face 1. Assemble equipment. Read and follow
mask, and eye protection) the manufacturer’s instructions for the
NOTE: I.R.M. is a brand of a reinforced brand being used.
zinc oxide eugenol (ZOE). Other brands 2. Wash hands. Put on personal protective
include Cavitec, Wonder Pak, and Inter- equipment.
PROCEDURE 18:13D
CAUTION: Observe standard precau- the cap of the bottle containing the liq-
tions while assisting with any dental uid immediately.
procedure.
NOTE: Prolonged contact between the
3. Fluff the powder by gently shaking the dropper and the liquid eugenol will
container. This ensures uniform bulk cause deterioration of the dropper, so
density of the contents. Open the lid the dropper is not stored in the liquid. If
carefully to avoid inhaling the powder. the cap is left off the bottle, evaporation
of the liquid will occur.
4. Fill the powder scoop to excess without
packing. Use the spatula to level the 7. Use the spatula to mix half of the pow-
scoop (figure 18-74A). Place the powder der and all of the liquid (figure 18-74C).
on the mixing pad. Use a stropping action with the spatula
to thoroughly combine this powder with
5. Dispense one drop of liquid for each
the liquid.
scoop of powder used or follow manu-
facturer’s instructions. Dispense the 8. Add the rest of the powder to the mix in
drop of liquid on the pad next to the two or three increments. Spatulate thor-
powder (figure 18-74B). oughly to mix.
CAUTION: Do not drop the liquid into NOTE: Some manufacturers recom-
the powder. mend mixing all of the powder with the
liquid at one time. Others recommend
6. Return the empty dropper into the
dividing the powder into four equal
holder on the outside of the bottle. Close
amounts. For this reason, it is essential
to follow manufacturer’s directions.
9. When all of the powder has been added,
whip the mix vigorously for 5–10 sec-
onds. The final mix should be smooth
and adaptable.
NOTE: Total mixing should be complete
in 1 to 11⁄2 minutes.
10. Pass the mix and the preferred instru-
ment to the doctor. The initial set occurs
approximately 3–5 minutes from the
FIGURE 18-74A Use a spatula to level the start of mixing, so work quickly and effi-
powder in the scoop. ciently.
FIGURE 18-74C To begin mixing the powder

FIGURE 18-74B Dispense the liquid onto the and liquid, use the spatula to add half the
pad next to the powder. powder to the liquid and mix thoroughly.
632 CHAPTER 18
PROCEDURE 18:13D
11. Clean and replace all equipment. Check
to be sure the lids on the bottles of pow-
der and liquid are secure. Tear the sheet
off of the mixing pad and discard the Practice
sheet in a waste container. Use orange Go to the workbook and use the
solvent or alcohol to clean the spatula evaluation sheet for 18:13D,
and other instruments. Scrub and steril- Preparing Zinc Oxide Eugenol
ize all instruments. (ZOE), to practice this procedure.
Final Checkpoint Using the criteria further action.
18:14 INFORMATION ♦ Amalgam alloy contains four main met-

als. Each metal has certain properties
Preparing Restorative that help form a durable restoration. To ensure
a uniform product, the American Dental Asso-
Materials—Amalgam and ciation has established percentages by weight
Composite for each of these metals. The metals and their
A main method of treating dental caries is resto- properties are as follows:
ration by the placement of filling materials. Res- (1) Silver is the main component. It provides
toration is defined as “the process of replacing high strength, low flow (resistance to
a diseased portion of a tooth or a lost tooth by change in shape under biting forces), high
artificial means.” This may include filling mate- expansion, rapid setting, and silver color.
rial, a crown, bridge, denture, partial denture, or (2) Tin is added to counterbalance the silver.
implant. It reduces expansion, slows setting time,
Dental caries, or decay, is a disease process reduces strength, increases the ability of
that attacks the hard tissues of the teeth, demin- the alloy to combine with mercury, and
eralizing and eventually destroying these tissues. allows the restoration to be carved.
When the enamel, dentin, and/or cementum are (3) Copper is added in small amounts to pro-
destroyed, a hollow space called a cavity is cre- vide increased strength, hardness, and low
ated in the tooth. To repair the damage caused by flow; to increase expansion; and to stabi-
a carious lesion, the doctor removes the decayed lize the other metals. It should make up
and damaged tissue and fills the cavity prepara- 12–30 percent of a high-copper alloy. An
tion with a restorative material, or filling. Two of amalgam containing 4–5 percent copper
the most commonly used restorative materials is called a low-copper alloy, a type used
are amalgam and composite. less frequently.
(4) Zinc is used in very small amounts to
remove oxides and other impurities. It is
AMALGAM sometimes referred to as a scavenger metal.
It is not used in all alloys.
Dental amalgam is a restorative material used
♦ Mercury is a metal that is a liquid at room tem-
primarily on posterior teeth.
perature. It is added to other metals to form
♦ Dental amalgam is a mixture of metals (an amalgam. It must be handled with care
alloy) combined with the metal mercury. because it is highly toxic. It can vaporize
(evaporate and float freely in the air) and be and sealed polyethylene bag. Scrap amalgam
absorbed into the body through inhalation or should be submerged in a tightly sealed,
skin pores. Mercury vapor has no odor, color, unbreakable jar containing sulfur water, glyc-
or taste, and is extremely difficult to detect. erin, or mineral oil. Most dental offices have a
Many sources can produce a vapor. Examples program of mercury hygiene to control mer-
include a leaking capsule, a mercury spill, air cury hazards. The dental assistant must
exposure while preparing and dispensing become familiar with this program and follow
amalgam, particle release while polishing a established regulations.
restoration or removing old amalgam restora- ♦ Amalgamation is the process that occurs when
tions, and/or improper storage of amalgam amalgam alloy is mixed with mercury. A new
scraps. Even carpeting in a treatment room alloy is formed, which becomes the restorative
can retain amalgam particles; vacuuming can (filling) material, called dental amalgam.
cause the mercury to vaporize into the air.
Personal protective equipment (PPE), includ- ♦ Trituration is the mixing process used to com-
ing disposable gloves, a gown, a face mask, bine mercury with the amalgam alloy. It is
and eye protection (glasses or a face shield) done with a mechanical amalgamator (a mix-
must be worn while working with dental amal- ing machine). It is important to follow the
gam. If skin is accidentally exposed to mer- manufacturer’s instructions regarding mixing
cury, the skin should be scrubbed with soap (trituration) time.
and water and rinsed thoroughly. Mercury ♦ Amalgam alloy is available in pellets or pow-
must be stored in well-sealed, unbreakable der and as low-copper or high-copper alloys.
containers. Mercury spills should be cleaned Low-copper alloys, used less frequently, are
up immediately. Spill kits, containing gloves, a composed of comminuted (lathe-cut filings)
mercury-vapor respirator (to prevent inhala- or spherical particles. High-copper alloys are
tion of the mercury), a sulfur solution (to coat available as comminuted, spherical, or
the droplets), a syringe with a large needle (to admixed (combination of particles). Alloys
draw in the mercury), and polyethylene bags with smaller particles will usually produce a
are used to clean up spills (figure 18-75). In stronger amalgam restoration with a smoother
addition, proper cleanup is essential after surface. The type of alloy used depends on the
working with dental amalgam. Mercury- doctor’s preference.
contaminated items, such as gloves, masks, or ♦ Dental amalgam alloy is purchased in dispos-
used capsules should be discarded in a labeled able capsules containing premeasured
amounts of amalgam alloy powder and mer-
cury (figure 18-76). The American Dental
Association (ADA) encourages the use of these
premeasured capsules because they eliminate
FIGURE 18-76 Dental amalgam alloy is pur-

FIGURE 18-75 A mercury spill kit should be used chased in disposable capsules containing premea-
to clean up mercury to prevent mercuric poisoning. sured amounts of amalgam alloy and mercury.
634 CHAPTER 18
mercury dispensers and decrease the possibil-

ity of a mercury spill, accidental inhalation of
mercury vapor, or skin contact with the mer-
cury. A membrane inside the capsule sepa-
rates the amalgam alloy powder and mercury
until the capsule is used. Usually, the capsule
must be twisted or pressed to break the mem-
brane and combine the alloy powder and mer-
cury before the capsule is placed in the
amalgamator for trituration.
♦ After amalgam has been triturated, it must be
used immediately to produce a good restora-
tion. The doctor uses an amalgam carrier to
place the amalgam in the prepared cavity. The
amalgam is then condensed, or packed, into
the cavity preparation, after which the resto-
ration is carved to correct occlusion (align-
ment between maxillary and mandibular
teeth) and tooth contour.
FIGURE 18-77 A curing light is used on light-
♦ Amalgam bonding agents are used for many cured composite to cause polymerization or harden-
restorations. These agents help the amalgam ing. (Courtesy of Lasermed, Inc., Salt Lake City,
adhere to the tooth surfaces and increase the Utah)
retention of the restoration. It is important to
follow the manufacturer’s recommendations
while using any bonding agents.
available in a premixed, syringe form. It is avail-
able in various shades to blend with the teeth.
COMPOSITE The amount needed is dispensed from the syringe
and then placed in the tooth cavity. When the res-
Composite is the restorative material used toration is in place, a curing light is used on the
most frequently in the repair of anterior composite, and the material sets (polymerizes).
teeth, but it can also be used to restore posterior Both the doctor and the dental assistant must
teeth. In comparison to other, older resins, com- wear light-filtering glasses or use light-screening
posite offers improved appearance, increased paddles while using the curing light to prevent
strength, and the ability to withstand chemical eye damage. The patient should also be given
actions caused by mouth fluids. It has an organic light-filtering glasses or asked to close his or her
polymer matrix, such as dimethacrylate, and eyes when the curing light is used. Before the
inorganic filler particles such as quartz and/or composite is placed in the prepared cavity, the
lithium aluminum silicate. Self-curing, or cavity is etched, and a bonding agent, or resin, is
chemical-curing, composite is supplied as two applied. The etching solution roughens the sur-
pastes that are mixed together to cause a chemi- face so that the composite will adhere (stick) and
cal reaction. One paste is a base, and the other is bond more securely to the tooth tissue. The bond-
an accelerator (catalyst). When the composite ing agent is then applied to help the composite
base and accelerator are mixed together, sub- material adhere to the tooth. Before using any
stances present in the base and accelerator cause composite, etching, or bonding materials, read
the reaction called polymerization, which results and follow the manufacturer’s instructions.
in a hardening of the material. Light-cured com-
posite is the most widely used type of composite. STUDENT: Go to the workbook and complete
It is sensitive to light, and polymerization does the assignment sheet for 18:14, Preparing Restor-
not occur until the composite is exposed to a cur- ative Materials—Amalgam and Composite. Then
ing light (figure 18-77). Light-cured composite is return and continue with the procedures.
PROCEDURE 18:14A
Preparing Amalgam
Premeasured amalgam capsule, amalgam-
ator, amalgam carrier, amalgam well or dap-
pen dish, amalgam instruments, articulating
paper, personal protective equipment (gloves,
gown, face mask, and eye protection)
Procedure FIGURE 18-78A Some disposable amalgam

capsules are activated by pressing the two ends
1. Wash hands. Put on personal protective of the capsule together to break the membrane
equipment. and combine the alloy powder and mercury.
Some brands of capsules must be twisted.
CAUTION: Observe standard precau- Follow manufacturer’s instructions. (Courtesy of
tions while assisting with any dental Patrick Reineck, DDS)
procedure.
3. Assist the doctor as required for prepa-
ration of the cavity.
4. If a bonding agent is used, read and fol-
low the manufacturer’s instructions to
prepare the materials for the doctor. The
bonding agent helps the amalgam
adhere to the exposed tooth surfaces.
5. Prepare the amalgam capsule according
to manufacturer’s instructions. Some
capsules are activated by twisting the
cap to break a seal and combine the
amalgam alloy with the mercury. Other
capsules are activated by pressing the
capsule together (figure 18-78A). FIGURE 18-78B Place the capsule in the
amalgamator. Read the manufacturer’s instruc-
CAUTION: Avoid skin contact with the tions for correct trituration time.
mercury. Also, avoid inhalation of mer-
cury vapors. Both may lead to mercury
poisoning. 7. When the doctor has completed the
cavity preparation, push the start but-
6. Place the capsule in the amalgamator
ton on the amalgamator to start tritura-
(figure 18-78B). Close the cover of the
tion.
amalgamator to enclose the capsule. Set
the timer for the correct time. Follow the 8. The amalgamator will turn off automat-
manufacturer’s instructions for tritura- ically when trituration is complete.
tion time. Remove the capsule from the amalgam-
ator and unscrew the capsule. Tap both
NOTE: Time is usually 7–10 seconds.
ends into an amalgam well or dappen
dish to empty the container.
636 CHAPTER 18
PROCEDURE 18:14A
9. Fill the amalgam carrier. The carrier 12. After the amalgam has been condensed,
should be packed tightly, smoothly, and pass the carving instruments. The resto-
quickly (figure 18-78C). ration must be carved so that correct
occlusion and contour is achieved.
10. Pass the filled carrier to the doctor (fig-
ure 18-78D). Be ready to pass a condens- 13. At all times, have the tri-flow syringe
ing instrument, because the amalgam and oral evacuator ready to rinse the
must be condensed into the tooth. patient’s mouth and remove excess
amalgam particles and liquids.
11. Repeat steps 9 and 10 until the cavity
preparation is filled. It may be necessary 14. Pass articulating paper when the doctor
to prepare a new mix of amalgam for is ready to check occlusion (figure 18-
large cavities. 78E).
NOTE: Setting time is usually 3–4 min- 15. When the restoration is complete, make
utes, so work quickly. sure the patient receives correct instruc-
tions. Most patients are told not to put
pressure on the new restoration for 1–2
hours. Some doctors recommend a soft
diet or suggest that the patient not use
the area for chewing for 1–8 hours. Some
doctors request a follow-up appoint-
ment to check and polish the restora-
tion.
NOTE: Before the restoration can be
polished properly, it usually must set for
24 hours. Polishing helps prolong the
life of the restoration.
16. Clean and replace all equipment. Scrub
and sterilize all instruments. Place any
disposable items contaminated with
FIGURE 18-78C The amalgam carrier should mercury in a sealed polyethylene bag.
be packed tightly, smoothly, and quickly. Submerge any unused, mixed amalgam
FIGURE 18-78E Articulating paper is used

FIGURE 18-78D Pass the filled amalgam to check occlusion when the restoration is
carrier to the doctor. complete.
PROCEDURE 18:14A
in a tightly sealed, unbreakable con- 17. Remove personal protective equipment.
tainer containing sulfur water, glycerin, Wash hands thoroughly.
or mineral oil (figure 18-78F). Many
offices save this amalgam and return a
large amount of it to manufacturers who
reclaim the silver.
Practice
Preparing Amalgam, to practice this
for further action.
FIGURE 18-78F Scrap amalgam must be Final Checkpoint Using the criteria
stored in a tightly sealed, unbreakable container listed on the evaluation sheet, your
containing sulfur water, glycerin, or mineral oil. instructor will grade your performance.
PROCEDURE 18:14B
Preparing Composite tions while assisting with any dental
procedure.
Equipment and Supplies 3. Assist doctor as required for the cavity
Etching liquid, resin (universal and catalyst), preparation.
composite (universal and catalyst) or light- 4. Open the bottle of etching liquid. Dis-
cured composite syringe, cotton pellets, cot- pense one to two drops on a mixing pad.
ton pliers, mixing pads, mixing stick, plastic Moisten a cotton pellet in the liquid.
composite instruments, personal protective Pass cotton pliers and the moistened
equipment (gloves, gown, face mask, and eye pellet to the doctor.
protection)
NOTE: Etching liquid can also be dis-
Procedure pensed into a disposable, plastic well
and placed on a disposable brush for
1. Assemble equipment. placement in the cavity. Wells and
brushes are supplied with certain brands
2. Wash hands. Put on personal protective of etching liquid.
equipment.
638 CHAPTER 18
PROCEDURE 18:14B
NOTE: The doctor etches the surface for
approximately 1 minute. This roughens
the tooth surface to increase bond
strength.
NOTE: If dentin is exposed, a calcium
hydroxide base may be placed on the
area prior to etching.
5. Pass the tri-flow syringe. The restorative
area must be washed thoroughly with
oil-free water and then dried after etch-
ing.
6. Prepare the bonding agent (resin). Place FIGURE 18-79A Avoid contaminating the jars of
equal amounts (one to two drops) of composite universal and catalyst by using opposite
universal and catalyst on a mixing pad ends of the mixing stick as you remove materials
or in a disposable, plastic well. Mix thor- from the jars.
oughly for 5–10 seconds with a fine
brush or plastic placement instrument.
NOTE: If a premixed, light-cured com-
The doctor will apply this to the tooth
posite is used, dispense the amount
surface.
required from the syringe (figure 18-79B).
NOTE: The bonding agent (resin) helps This type of composite material does
the composite material adhere to the not have to be mixed.
tooth.
8. Use plastic composite instruments to
CAUTION: Take care to avoid contami- pass the prepared composite paste to
nating the contents of the universal the doctor.
container with those of the catalyst con-
NOTE: Plastic instruments will not dis-
tainer. Such contamination may cause a
color the mix. They also reduce the ten-
reaction that destroys the contents of
dency of the composite to stick to the
both containers.
instruments.
7. Prepare the composite. Place an amount
9. Refill the instruments with composite
of universal paste equal to approxi-
mix as needed. Work quickly but effi-
mately half the size of the cavity on the
ciently.
mixing pad; use one end of the mixing
stick (usually marked U) . Use the oppo-
site end of the mixing stick (usually
curved and marked C) to place an equal
amount of catalyst on the mixing pad.
Mix the two pastes together for approxi-
mately 20 seconds and until the mix is
smooth and well blended.
CAUTION: Again, take care to avoid
contaminating the contents of the uni-
versal jar with those of the catalyst jar
(figure 18-79A). Such contamination
may cause a reaction that destroys the FIGURE 18-79B If a premixed, light-cured
composite is used, dispense the amount
contents of both jars.
required from the syringe.
PROCEDURE 18:14B
NOTE: Setting usually occurs 4 minutes 12. Replace all equipment. Check to make
after mixing. This allows approximately sure the lids on all containers are
1–2 minutes for placement. securely in place.
NOTE: If light-sensitive composite resin 13. Remove personal protective equipment.
is used, the curing light is given to the Wash hands.
doctor when the restoration is in place.
The material will not harden, or set,
until it is exposed to this light.
CAUTION: The doctor and the dental
assistant must wear light-filtering
Practice
glasses or use light-screening paddles
while using the curing light. The patient evaluation sheet for 18:14B,
must also be given light-filtering glasses Preparing Composite, to practice
or asked to close his or her eyes. this procedure. When you believe
10. Have composite finishing and polishing the sheet and give it to your
strips ready for use. instructor for further action.
11. Clean materials from instruments
immediately. The mixing sticks are usu-
ally disposable. Discard these immedi- Final Checkpoint Using the criteria
ately to avoid contaminating the jars. listed on the evaluation sheet, your
Scrub and sterilize all instruments. instructor will grade your performance.
appear very white, or radiopaque, on X-rays.

18:15 INFORMATION
There are several different types of dental radio-
Developing and Mounting Dental graphs:
Radiographs (X-Rays) ♦ Bite-wings (BWXR): These show only the
The dental assistant develops and mounts dental crowns of the maxillary and mandibular teeth
X-rays or radiographs. Dental radiographs are (figure 18-80). They are called cavity-detecting
negatives taken of the teeth, similar to the nega- radiographs because they are primarily used
tives received when photographs are taken. X-ray to detect interproximal (between the teeth)
beams are passed through the teeth and tissues. decay and recurring decay under restorations.
A series of shadows are then produced on film. They do not show root-end infection or
Images on the developed film are described as abscess. Usually, two to four bite-wings are
radiolucent or radiopaque: taken of the posterior teeth. Sometimes two to
♦ Radiolucent: These areas appear dark on

radiographs. This means that the X-rays pen-
etrate through the structures. Examples of
these areas are the pulp and caries.
♦ Radiopaque: These areas appear light or
white on radiographs. This means that the
structures stop the X-rays, or that the X-rays
are unable to penetrate the structures. Most
tooth structures, including enamel and den- FIGURE 18-80 Bite-wing (BW) X-rays show only
tin, are radiopaque. Metallic restorations also the crowns of the maxillary and mandibular teeth.
640 CHAPTER 18
four bite-wings are taken of anterior teeth in

adults. Two common sizes of bite-wing film
include: size 1 used for anterior teeth, and size
3 used for posterior teeth.
♦ Periapical films (PA): These show the tooth
and the surrounding area, and can show root-
end infection. They are also used to determine
the number and shape of roots, the condition
of supporting structures of the teeth, and the
relationship of a tooth to other teeth. Usually,
14 periapical radiographs are taken for a full-
mouth series. This shows the complete denti-
tion (figure 18-81). Size 2 film is usually used
for periapical films, but a size 1 film can be
used for adults with small mouths or children
over 6 years of age.
♦ Pedodontic (child) films: These are smaller
films, usually size 0, used on children to show
disease or other conditions of the teeth. Both
bite-wings (BWs) and periapicals (PAs) are
taken.
♦ Occlusal films: These films, size 4, are
approximately twice the size of a number 2
film. They are used to view the occlusal (chew-
ing) planes of the maxilla or mandible.
♦ Panoramic: This is a special type of film that
shows the entire dental arch, or all of the
teeth, on one film. The film is placed in a film
FIGURE 18-82A After a patient is positioned in a
cassette in a panoramic X-ray unit that rotates panoramic X-ray machine, the unit rotates around
around the patient’s head (figure 18-82A). One the patient’s head.
developed film shows complete dentition,
bone structure, and surrounding tissues (fig-
ure 18-82B).
Care must be taken while developing films.
Developing involves a series of chemical
reactions. The following points should be noted:
♦ Dental film is specially prepared and wrapped
in a packet containing moisture-proof paper.
The film is between two sheets of protective
black paper. It is backed with lead foil. The
FIGURE 18-82B A panoramic X-ray shows
complete dentition, bone structure, and surrounding
tissue.
lead foil stops the X-ray beams once they have

passed through the teeth structures to the film
(figure 18-83).
FIGURE 18-81 A full-mouth series of periapical ♦ Exposure of the film to light will destroy the
(PA) X-rays shows the crowns and roots of all the image on the film. Film must be opened and
teeth. exposed in a darkroom. Only safety darkroom
according to the manufacturer’s instructions.

Fixing solution must be replaced when it is
diluted, outdated, or causing poor-quality
images on the film.
♦ The developing and fixing solutions must be
monitored daily for temperature, amount,
cleanliness, and quality. Read and follow the
manufacturer’s instructions provided with the
solutions. The solutions must be handled with
care because they are toxic to the skin and
eyes. Personal protective equipment must be
worn when handling, mixing, replenishing, or
disposing of solutions.
♦ Temperature of the developer, fixer, and water
used should be 68°F, or 20°C. All solutions
should be mixed well before using.
♦ Most offices have automatic developing
machines. Manufacturer’s instructions should
be followed.
FIGURE 18-83 The lead foil in the packet of Radiographs are placed in special mounts for
radiographic film stops the X-ray beams after they
viewing. They must be mounted correctly.
have passed through the teeth structures.
♦ Each film contains a dimple. This dimple
points toward the X-ray machine. One side of
lights should be used. No outside light can the film shows a concave (pointing inward)
enter the room during this procedure. dimple. The other side shows a convex (point-
♦ Dental film contains a film emulsion, with a ing outward) dimple.
layer of silver halide suspended in a gelatin. ♦ In one mount, all dimples must be facing the
The gelatin keeps the silver from settling and same direction.
keeps it suspended on the surface of the film.
♦ When all the dimples are convex (pointing
The X-ray beams reduce, or expose, some of
outward), you are viewing the facial surface
the silver salts. When the film is later exposed
(buccal or labial). When the films are placed in
to chemicals, the chemicals act on the exposed
the mount in this manner, the films on your
silver to create the shadows seen on the X-
left are the patient’s right teeth, and the films
ray.
on your right are the patient’s left teeth. This is
♦ Care must be taken while the film is being the most widely used method for mounting
unwrapped. Hands must be clean and dry. X-rays because most dental charts use this
Personal protective equipment, including facial view of the teeth.
gloves and eye protection, must be worn. Fin-
♦ When all the dimples are concave (pointing
gerprints and marks can damage the film.
inward), you are viewing the lingual (tongue)
Handle the film by the edges only.
surface. Thus, the films on your right are the
♦ Developing solution is used to break down the patient’s right teeth, and the films on your left
exposed silver. This fluid is a chemical mixture are the patient’s left teeth.
that is alkaline in nature. It must be mixed
♦ The doctor determines the manner in which
according to the manufacturer’s directions.
films should be mounted.
Developing fluid must be replaced periodi-
cally when it is diluted, outdated, or causing
poor-quality images on the film. STUDENT: Go to the workbook and complete
♦ Fixing solution is used to stop the developing the assignment sheet for 18:15, Developing and
process. Fixing solution is a chemical solution Mounting Dental Radiographs (X-Rays). Then
that is acidic in nature. It must be mixed return and continue with the procedures.
642 CHAPTER 18
PROCEDURE 18:15A
CAUTION: Avoid getting fingerprints or
Developing Dental marks on the film.
Radiographs (X-rays) 8. Clip the film on the film rack. Tug gently
to be sure the film is securely in place.
Equipment and Supplies NOTE: If the film is loose, it may fall off
Exposed dental X-ray film, darkroom, devel- the rack and into the solutions.
oping tanks, film clip rack, pen, personal pro- 9. When all films from one patient have
tective equipment (gloves, gown, face mask, been placed on the film rack, use a pen
and protective eyewear) to label one plastic, waterproof wrap
NOTE: This procedure would not be used with the patient’s name. Place this name
with an automatic processor or developer. wrap on the clip above the patient’s
Follow manufacturer’s instructions on the films.
automatic units. NOTE: This identifies films when more
than one set are processed.
Procedure 10. Smoothly immerse the film into the
developer (figure 18-84A and B). Gently
agitate the hanger up and down several
2. Wash hands. Put on personal protective times to make sure the film is coated
equipment. with developer. Hook the hanger over
NOTE: The exposed X-ray film may be the side of the tank, making sure all of
contaminated with saliva or mouth the films are below the level of solution
fluids. in the tank. Set the timer for 5 minutes
or the developing time specified by the
3. Use separate stirring rods to stir the
manufacturer of the film and solution.
developing and fixing solutions thor-
Cover the tank.
oughly. Avoid splashing the solution.
CAUTION: Avoid jerking motions while
4. Turn on the rinse water. Regulate the
putting the film in the developer. Jerk-
temperature at 68°F, or 20°C. The water
ing motions will cause streaking of the
bath should be running constantly.
film.
NOTE: This ensures a clean supply of
NOTE: Check the time charts provided
water for rinsing.
with solutions and film speeds to deter-
5. Secure the darkroom. Close all doors mine the correct developing time. Cor-
tightly. Turn on the outside warning rect time and temperature are essential
light. Turn off the main lights. Turn on for diagnostically acceptable radio-
the safe lights. graphs. Many ultraspeed films develop
CAUTION: Any beam of light will destroy in 2 minutes or less.
the X-ray film. Double-check for any NOTE: Tanks should be kept covered to
light beams. prevent evaporation of solutions.
6. Unwrap the film. Turn the tab toward 11. At the end of the developing time, lift
you. Pull open the tab. Pull the black the film rack out of the developing solu-
paper out approximately one-half its tion. Gently shake off excess solution.
length. Fold back the lead shield and the
12. Place the rack in the running-water
moisture-proof paper to expose the film.
bath. Agitate the rack up and down sev-
7. Use a gloved thumb and forefinger to eral times so that the film surfaces are
grasp the sides of the film. Gently remove thoroughly rinsed for at least 30 sec-
the film from the pack. onds.
PROCEDURE 18:15A
NOTE: Film is usually left in the fixer
twice as long as it is left in the developer.
NOTE: This stops the developing process.
The fixer clears the film and hardens it.
15. When the fixing time is complete,
remove the film rack from the fixing
solution. Shake off excess solution.
16. Rinse the rack in the water bath. Agitate
the rack to cover the films with water.
Rinse the films for at least 20 minutes.
Cover the tanks.
NOTE: Films can be left in the final rinse
for longer periods.
17. At the end of the rinse period, put the film
rack on a drying rack. Make sure the films
are not in contact with any surface (for
example, a wall) while they are drying.
NOTE: Films should be thoroughly dried
A before being removed from the film
Overflow Thermostat
valve Thermometer
Cold water
rack. They should not be handled or
mounted until dry.
Hot water 18. Clean all solutions off the countertops
Water
or sink immediately. Replace all sup-
Fixer
Developer
bath plies. Make sure the tanks are covered
prior to leaving the darkroom area.
19. If no further films are to be developed,
turn off the running-water bath. In a
dental office, this bath is always turned
B off at the end of the day.
Drain
FIGURE 18-84 (A) Smoothly immerse the Wash hands.
film in the developing solution. (B) The develop-
ing solution is on the left and separated from
the fixing solution on the right by the water bath.
NOTE: This helps remove the developer Practice
from the films. In this way, developing Go to the workbook and use the
solution will not contaminate the fixing evaluation sheet for 18:15A,
solution. Developing Dental Radiographs
(X-Rays), to practice this procedure.
13. Hold the rack above the water bath and When you believe you have
gently shake off excess water.
14. Place the rack in the fixing solution. Agi- and give it to your instructor for
tate the rack up and down to cover all further action.
surfaces of the film. Set the timer for 10
minutes or the time specified by the film Final Checkpoint Using the criteria
and solution manufacturers. Cover the listed on the evaluation sheet, your
tanks. instructor will grade your performance.
644 CHAPTER 18
PROCEDURE 18:15B
f. Mandibular lateral incisors are wider
Mounting Dental than mandibular central incisors.
Radiographs (X-rays) g. Maxillary cuspids are the longest
teeth in the mouth.
Equipment and Supplies h. Maxillary molars each have three
Developed, full-mouth series of radiographs; blurred roots.
X-ray mounts; view box
i. Mandibular molars each have two
distinct roots.
Procedure
6. Locate the four (or two) bite-wings
1. Assemble equipment. Label the X-ray (BW). Mount these in the correct areas
mount with the patient’s name and the on the mount (figure 18-85). The bicus-
date the films were taken. pid views should be placed closer to the
center of the mount.
2. Wash hands.
7. Locate the two central incisor (CI) and
3. Turn on view box. Make sure surface is lateral incisor (LI) films. Look at the size
dry and clean. of the teeth to determine which are
4. Lay out the series of radiographs on the maxillary films and which are mandibu-
view box. Make sure each dimple is lar films. Mount the maxillary films with
pointing in the same direction, that is, the roots pointing upward. Mount the
either concave (inward) or convex (out- mandibular films with the roots point-
ward). ing downward.
NOTE: Convex is the facial-surface 8. Locate the four cuspid (C) films. The
view; concave is the lingual-surface larger or longer cuspids are maxillary.
view. Most doctors prefer the facial Note the incisors and bicuspids on
view. either side of the cuspids. Mount the
cuspid films in the correct areas on the
NOTE: A full-mouth series of X-rays usu-
mount.
ally consists of 14 periapical films plus
2–4 bite-wings. 9. Locate the four bicuspid (B) films. The
maxillary 1st bicuspid is the only bicus-
5. Review the following facts about denti-
tion. They are essential for mounting
films: M.– B.– B.– M.–
B.W. B.W. Maxillary Arch B.W. B.W.
a. Bite-wing X-rays show only the
crowns of maxillary and mandibular L. I.
M. B. C. C. B. M.
teeth. C. I.
b. Periapical films show the crowns and

roots of teeth. M. B. C.
C. I.
C.
L. I. B. M.
c. Maxillary films often each have a
hazy or swirly area, which is the max- Mandibular Arch
illary sinus.
Abbreviations:
d. Maxillary central incisors are larger B.W. Bite-wings C. Cuspids
C.I. Central incisors . Bicuspids
B.
than mandibular central incisors. L.I. Lateral incisors M. Molars
e. Maxillary lateral incisors are larger FIGURE 18-85 Correct placement for a full-
than mandibular lateral incisors. mouth series of X-rays.
PROCEDURE 18:15B
pid that is bifurcated (having two roots). pointing in the same direction. One
Note the two maxillary films. Place them reversed dimple can cause a great deal
in the mount by noting cuspids and of difficulty.
molars on either side. Do the same for
12. Recheck the entire mount for accuracy,
the mandibular bicuspids.
noting the facts listed in Step 5. Make
10. Locate the four molar (M) films. Note sure all maxillary roots are pointing
the blurred, trifurcated (three) roots of upward and all mandibular roots are
the maxillary molars. Look for hazy or pointing downward.
swirly areas that indicate the maxillary
13. Clean and replace all equipment. Turn
sinuses. Note the arch curvature in the
off view box.
back of the mouth. Place these films in
the correct mount positions. Note the 14. Wash hands.
bifurcated (two) roots of the mandibu-
lar molars. Use the arch and bicuspid
locations to place these films in the cor-
rect mount positions.
NOTE: Some people find it easier to
Practice
mount all maxillary films and then all
mandibular films. Either way is satisfac- evaluation sheet for 18:15B,
tory. Mounting Dental Radiographs
(X-Rays), to practice this procedure.
11. Check whether there are restorations on When you believe you have
the films, for purposes of comparison mastered this skill, sign the sheet
and verification of placement accuracy. and give it to your instructor for
Restorations can also serve as clues to further action.
placement when the quality of one film
is poor or the film has been taken incor-
rectly.
NOTE: If the films do not fit, always listed on the evaluation sheet, your
check the dimples to be sure they are instructor will grade your performance.
646 CHAPTER 18

Stromal stem cells to prevent tooth loss?
When a tooth is lost or removed, a gradual deterioration of the bony tissue from the jaw-
bone at the site of the missing tooth occurs. This bone loss can spread and lead to a loss of
bone structure supporting the surrounding teeth, which causes the eventual loss of those
teeth. In addition, the bone loss that occurs can make the use of dental implants less feasible.
Researchers have found that bone regeneration is affected by the fact that different cel-
lular components in tissue have varying rates of migration into the damaged bone area dur-
ing the healing process. They know that, for osteogenesis (the development and formation
of bone tissue) to occur, cells that can form bone must be allowed to migrate to the affected
area of damaged bone. Research has indicated that stromal stem cells found in soft connec-
tive tissue are able to create cells that are osteogenic. Studies are currently under way that
involve removing bone marrow from the pelvic (hip) bone and grafting it to the jaw bone to
encourage the development of new bone. Researchers hope that the osteogenic cells in the
bone marrow will aid in restoring the bone structure by the missing tooth.
An additional research study is evaluating the effect of creating a mechanical hindrance
to prevent other cells such as fibroblasts and soft connective tissue cells from entering the
area of bone loss. These cells build up soft connective tissue and interfere with the develop-
ment of bone tissue. Researchers used a Teflon membrane on some animals before the graft-
ing of the osteogenic cells. Fifty percent of the animals had complete healing of the bone
after 3 weeks, and all of the animals had complete healing after 6 weeks. Animals without
the Teflon membrane had little healing after 22 weeks.
Additional research is being conducted with the hope that in the near future there will be
an effective way of restoring bone tissue in the jaw. If these theories prove correct, a person
will no longer lose bone tissue and endanger surrounding teeth after a tooth is lost. Dental
implants will be more effective and individuals will have functioning teeth.
CHAPTER 18 SUMMARY dental restorative or orthodontic treatment is

necessary. In addition, custom trays are made to
obtain more exact models of patients’ mouths.
Many different skills are performed by the den- A knowledge of basic dental instruments
tal assistant. Some of the more common skills allows the dental assistant to assist the doctor
were discussed in this chapter. when basic dental restorative procedures are per-
A knowledge of the structure, names, and formed. The use of amalgam or composite as re-
surfaces of the teeth is essential. The dental as- storative or filling material for teeth with carious
sistant must also be familiar with the Universal/ lesions or decay is one of the most common pro-
National Numbering System and the Federation cedures. The dental assistant helps by preparing
Dentaire International System for identifying dental anesthetic materials, mixing bases and ce-
teeth. This knowledge allows the dental assis- ments, and preparing restorative materials. After
tant to help with charting dental conditions and procedures are complete, the dental assistant is
provides a better understanding of the proce- often responsible for the maintenance and care
dures performed by the doctor. This knowledge of the equipment and instruments used.
is also necessary to develop and mount dental By mastering the basic skills, the dental as-
radiographs. sistant can become a valuable member of the
Taking impressions and pouring models of dental team and help provide quality dental care
the teeth are tasks frequently performed when to the patient.
5. List the main dental instruments that would be

INTERNET SEARCHES placed on the tray for each of the following
procedures:
Use the suggested search engine in Chapter 12:4 a. prophylactic and oral examination
of this textbook to search the Internet for addi- b. amalgam restoration
tional information on the following topics: c. composite restoration
1. Organization: search the Web sites for the d. surgical extraction
American Dental Association, American Dental 6. If teeth are brushed correctly, why must they
Hygienists’ Association, and the American be flossed?
Dental Assistants’ Association to obtain
information on dental careers 7. Differentiate between general anesthesia,
analgesia or sedation, local anesthesia, and
2. Dental anatomy: research information on the topical anesthesia.
tissues of a tooth (enamel, dentin, pulp, and
cementum), periodontium (alveolar process, 8. State the main function of a dental varnish,
periodontal ligament, and gingiva), and base, cement, and temporary.
eruption of teeth 9. Why is mercury dangerous? List four (4) safety
3. Restorative treatments: research amalgam, precautions that must be observed while
composite, prophylactic treatments (for working with mercury and dental amalgam.
example, fluoride), orthdontic treatment, and 10. Draw a diagram of the fourteen (14) periapical
periodontic treatment films for a full-mouth series of radiographs.
4. Dental supply companies: search for suppliers Identify the teeth that are shown in each film.
of dental instruments, equipment, and materi- For additional information on dental careers,
als to compare and contrast the products contact the following associations:
available
♦ American Dental Assistants’ Association
33 East Wacker Drive, Suite 1730
REVIEW QUESTIONS Chicago, Illinois 60611
Internet address: www.dentalassistant.org
1. Draw a diagram of a tooth. Label the three (3)

♦ American Dental Association
211 E. Chicago Avenue
sections or divisions of the tooth, the four (4)
Chicago, Illinois 60611
tissues of the tooth, and the structures of the
Internet address: www.ada.org
periodontium.
♦ American Dental Hygienists’ Association
2. Name the five (5) surfaces, eight (8) line angles,
444 N. Michigan Avenue, Suite 3400
and four (4) point angles for both anterior and
posterior teeth.
Internet address: www.adha.org
3. Identify both the Universal/National Number- ♦ National Association of Dental Laboratories
ing System and the Federation Dentaire 325 John Knox Road
International System code for each of the Tallahassee, FL 32303
following permanent teeth: Internet address: www.nadl.org
a. maxillary right central incisor
b. maxillary left 2nd molar
c. mandibular left cuspid
d. mandibular right 1st bicuspid
4. Explain the maintenance and disinfection
requirements for each of the following types of
dental equipment:
a. dental chair
b. dental light
c. tri-flow or air–water syringe
d. low-speed handpiece
CHAPTER 19 Laboratory
Assistant Skills
Chapter Objectives
Observe Standard ◆ Operate the microscope and identify its parts
Precautions
◆ Obtain a culture specimen without
contaminating it
◆ Streak an agar plate or slide
◆ Stain a bacterial slide using the Gram’s stain
technique
◆ Puncture the skin to obtain blood, observing
Caution
all safety factors
◆ Perform a microhematocrit
on Federal Law
◆ Perform a hemoglobin test with a
hemoglobinometer and a photometer
◆ Prepare and stain a blood smear using Wright’s
Math Skill stain
◆ Test blood for type and Rh factors using
Legal Responsibility antiserums
◆ Perform an erythrocyte sedimentation rate
(ESR)
Science Skill
◆ Measure blood-sugar (glucose) level
◆ Test urine using a reagent strip
Career Information
◆ Measure specific gravity of urine
◆ Prepare urine for microscopic examination
Technology
Laboratory Assistant Skills 649
KEY TERMS
agar plate glucose tolerance test (GTT) microscope
antibody screen glycohemoglobin test oliguria (oh-lih-goo-ree-ah)
anticoagulant (an-tie-coh- glycosuria (gly-coh-shur-ee- polyuria
ag-you-lant) ah) reagent strips
antigen (an-tih-jen) Gram’s stain refractometer (ree-frack-
anuria (ah-nur-ree-ah) hematocrit (Hct) (hih-mat- tum-ee-ter)
blood smear on-krit) resistant
culture specimen hematuria (hee-mah-tyour- sensitive
differential count ee-ah) skin puncture
direct smear hemoglobin (Hgb) (hee- specific gravity
erythrocyte (eh-rith-row- mow-glow-bin) typing and crossmatch
site) hemolysis (hih-mall-ah-sis) urinalysis (your-in-al-ee-
erythrocyte sedimentation hyperglycemia (high-purr- sis)
rate (ESR) gly-see-me-ah) urinary sediment
fasting blood sugar (FBS) hypoglycemia (high-poh- urinometer
glucose gly-see-me-ah)
venipuncture
leukocyte
CAREER HIGHLIGHTS
Medical, or clinical, laboratory personnel work under the supervision of doctors, usually
pathologists. They are important members of the health care team. They perform laboratory
tests on body tissues, fluids, and cells to aid in the detection, diagnosis, and treatment of
disease. Levels of personnel are the technologist, technician, and laboratory assistant. Med-
ical laboratory technologists perform more complex tests and usually have a bachelor’s or
master’s degree. Medical laboratory technicians perform less complex tests and usually have
an associate’s degree. Medical laboratory assistants perform basic laboratory tests and usu-
ally have specialized health occupation education training. Some states require laboratory
personnel to be licensed or registered. Certification can be obtained from the National Cre-
dentialing Agency for Laboratory Personnel or the American Medical Technologists Associa-
tion, each of which has specific requirements.
Any medical laboratory or medical office that performs tests on human specimens is
regulated by a federal amendment, the Clinical Laboratory Improvement Amendment
(CLIA) of 1988. CLIA established standards, regulations, and performance requirements
based on the complexity of a test and the risk factors associated with incorrect results. Lev-
els of complexity include waived tests, moderately complex tests, and highly complex tests.
Each of these levels has different requirements for personnel and quality control. Laborato-
ries are certified by the U.S. Department of Health and Human Services (USDHHS) based
on these levels. Therefore, medical laboratory assistants/medical assistants must follow all
legal requirements before performing any laboratory test. Some examples of waived tests, or
tests that can be performed by assistants if the agency where they are working has a CLIA
waiver certificate, include:
650 CHAPTER 19
CAREER HIGHLIGHTS
◆ Provider-performed ◆ Cholesterol monitoring by ◆ Comprehending human
microscopy tests (PPM) specific kits anatomy, physiology, and
such as pinworm, nasal ◆ Rapid streptococcal
pathophysiology with an
smear, and fecal leukocyte identification by specific emphasis on cells, tissues,
examinations kits and body fluids, especially
◆ Most urinary reagent strip
blood and urine
◆ Gastric occult blood
(dipstick) or reagent tablet ◆ Learning medical
tests ◆ Prothrombin time terminology
◆ Hematocrit and spun ◆ Triglyceride test ◆ Observing all safety
microhematocrit Many of the waived tests are precautions
◆ Erythrocyte discussed in this chapter. In ◆ Practicing all principles of
sedimentation rate addition to the knowledge infection control
(nonautomated) and skills presented in this
◆ Performing business and
chapter, medical laboratory
◆ Hemoglobin: copper accounting duties such as
assistants must also learn
sulfate (nonautomated) or and master skills such as: answering the telephone,
automated by scheduling appointments,
instruments with self- ◆ Presenting a professional preparing
contained components to appearance and attitude correspondence,
perform specimen– ◆ Obtaining knowledge completing insurance
reagent interaction and regarding health care forms, maintaining
provide direct delivery systems, accounts, and
measurement and organizational structure, maintaining patient
readout and teamwork records
◆ Blood glucose by glucose ◆ Meeting all legal ◆ Utilizing computer skills
testing devices cleared by responsibilities ◆ Cleaning and maintaining
the Food and Drug laboratory equipment
Administration ◆ Communicating
effectively ◆ Ordering and maintaining
◆ Ovulation and pregnancy
◆ Being sensitive to and supplies and materials
tests by visual color
comparison respecting cultural
diversity
◆ Fecal occult blood
piece, and a binocular microscope has two eye-

19:1 INFORMATION pieces. The quality of microscopes also varies,
according to the type of lenses, attachments, and
Operating the Microscope magnification ability. The compound, bright-
The microscope is an instrument used to field microscope, described in this chapter, is one
magnify and visualize objects too small to of the most commonly used microscopes. An epi-
be seen with the naked eye. It is a valuable tool fluorescence microscope is used to detect antibod-
used in many health professions. To obtain the ies and specific organisms by using a fluorescent
desired results when working with the micro- dye stain. An electron microscope, which is
scope, it is important to first become familiar extremely expensive and requires special exper-
with its parts and how to use them correctly. tise to operate, uses electron beams instead of a
Many different models of microscopes are light source to view objects (figure 19-1A). The
available. A monocular microscope has one eye- beam is passed through the specimen and the
FIGURE 19-1B Blood cells as seen with an

electron microscope. (Courtesy of Philips Electronic
Instruments Co.)
tion can range from 10X to 20X, depending on

how the eyepiece is positioned. Special lens
paper should be used to clean the eyepiece to
avoid scratching the lenses. The eyepiece is
also called the ocular viewpiece.
♦ Objectives: Objectives are the parts of the
microscope that magnify the object being
FIGURE 19-1A An electron microscope uses viewed. They work with the eyepiece. A micro-
electron beams instead of a light source to view scope may have three or four objectives, and
objects. (Courtesy of Philips Electronic Instruments they can vary. Some of the more common
Co.) objectives are:
(1) The low-power objective is the shortest in
image is projected onto a screen where it may be length. It magnifies the object being
enlarged and/or photographed. Electron micro- viewed four times (4X).
scopes are used to view extremely small objects (2) Another low-power objective magnifies
such as cell organelles, viruses, and blood cells the object 10 times (10X).
(figure 19-1B). (3) The high-power objectives magnify the
Most microscopes contain the same basic object 40 or 45 times (40X or 45X).
parts. A list and a brief description of the function (4) The oil-immersion (OI) objective usually
of each part follows. The parts of a microscope has a magnification power of 95X to 100X.
are shown in figure 19-2. Oil must be used with this objective
because the image is usually too dark to be
♦ Base: this is the solid stand on which the seen otherwise. The oil concentrates the
microscope rests. light. A drop of immersion oil is placed on
♦ Arm: this is the long, back stem of the micro- the slide. The oil-immersion objective is
scope. In most cases, the arm is used to carry carefully rotated into the drop of oil. Care
the microscope. must be taken to prevent the oil from
♦ Eyepiece(s): this is the part(s) of the micro- coming in contact with any of the other
scope through which the eye views the object objectives on the microscope.
or slide. The eyepiece usually has a magnifica- NOTE: Smaller specimens require greater
tion power of 10X (10 times). This means that magnification. However, the high-power
it makes the object on the slide appear 10 objectives have small openings. Therefore, to
times larger than normal. Some microscopes view small specimens, use a high-power
have zoom lenses. On these, the magnifica- objective and more light. For large speci-
652 CHAPTER 19
FIGURE 19-2 Parts of a microscope.
mens, use low-power objectives and less ♦ Condenser and iris diaphragm: This structure
light. Special lens paper should be used to is directly underneath the stage. The con-
clean the objectives. denser controls the intensity of light that
♦ Revolving nosepiece: This is the section to passes through to the specimen on the stage.
which the objectives are attached. It is turned It contains an iris diaphragm that regulates
to change the objective being used. the amount of light. The diaphragm is turned
to a larger or smaller hole to increase or
♦ Stage: The stage is the flat platform for the decrease the amount of light.
slide. Slide clips are located on the stage to
♦ Illuminating light: Located under the stage,
hold the slide in place.
the illuminating light provides the necessary
♦ Coarse adjustment: This is the larger knob on light for viewing; the amount of light is con-
the arm. It moves the objectives up and down, trolled by the iris diaphragm.
and also brings the slide into rough focus. The ♦ Body tube: This section connects the eyepiece
coarse adjustment should be used only on the and the objectives.
low-power (10X) objective. It is important to
watch the stage while moving the objectives to To determine total magnification of an
avoid breaking the slide and/or objectives. object (how many times you are magnifying
or enlarging the object), multiply the power of
♦ Fine adjustment: This is the smaller knob on the eyepiece times the power of the objective in
the arm. It moves the objectives slowly for a use.
precise and clear image. The fine adjustment
is used on the low-power (10X), high-power
♦ Example 1: If the eyepiece is 10X and the
objective is 4X, multiply the 10 and the 4.
(40–45X), and oil-immersion (95–100X) objec-
tives. 10 4 40
The object is magnified or enlarged 40 times

its original size.
♦ Example 2: Eyepiece is 20X and objective is
40X.
20 40 800
The object is magnified or enlarged 800
times.
Proper care and cleaning of any microscope is
important because dirt and dust can interfere with
proper viewing and damage the delicate glass on
the eyepiece and objectives. The glass in the eye-
piece and objectives should be cleaned with spe-
cial lens paper. Paper towels, tissues, and cloths
can scratch the delicate glass. The rest of the micro-
scope should be wiped clean with a damp, soft
cloth after use. When oil is used with an oil-
immersion objective, the oil should be wiped off
immediately after use because it can seep into the
lens case. Before storing the microscope, the low-
power objective should be in place and the nose-
piece should be moved to its lowest position. When
the microscope is not in use, it should be covered
with a dust cover or stored in a dust-free cabinet. It FIGURE 19-3 To carry a microscope, place one
is also important to avoid jarring or bumping the hand firmly on the arm and the other hand under
microscope because it is a delicate instrument. To the base.
carry or move a microscope, one hand should be
placed firmly on the arm and the other hand under
the base (figure 19-3). The microscope must be
put down gently when it is placed on a desk or STUDENT: Go to the workbook and complete
counter. It is important to read and follow the spe- the assignment sheet for 19:1, Operating the Micro-
cific operating instructions provided by the manu- scope. Then return and continue with the proce-
facturer before using any microscope. dure.
PROCEDURE 19:1
CAUTION: Wear gloves and observe
Operating the standard precautions while handling
Microscope any specimen contaminated by blood
or body fluids, or while examining
Equipment and Supplies pathogenic organisms.
3. Use a prepared slide or get a clean slide.
Microscope; lens paper; slide and coverslip;
Place a human hair, shred of paper, or
hair, paper, or other small object; drop of
other small object on the slide. Add a
water; immersion oil
drop of water or normal saline. Cover
with a clean coverslip by holding the
Procedure coverslip at an angle and allowing it to
drop on the specimen.
NOTE: Make sure there are no air bub-
2. Wash hands.
bles between the slide and coverslip. If
654 CHAPTER 19
PROCEDURE 19:1
air bubbles are present, remove the cov- objective moves down close to the
erslip and position it again. slide.
4. Use lens paper to clean the eyepiece CAUTION: Do not look into the eye-
(ocular viewpiece) and the objectives. piece while moving the objective down.
The objective could crack the slide and/
CAUTION: Do not use any other mate-
or be damaged.
rial to clean these surfaces. Towels, rags,
and tissues can scratch these surfaces. 9. Now, look through the eyepiece. Slowly
turn the body tube upward until the
5. Turn on the illuminating light. Open the
object comes into focus.
iris diaphragm so that the largest hole is
located directly under the hole in the 10. Change to the fine adjustment. Turn the
stage platform. knob slowly until the object comes into
its sharpest focus.
6. Turn the revolving nosepiece until the
low-power objective clicks into place. 11. Do the following while still using low
power:
7. Place the slide on the stage. Fasten it
with the slide clips. a. Move the slide to the right while look-
ing through the eyepiece. In which
NOTE: Avoid getting fingerprints or
direction does the image move?
smudges on the slide.
b. Move the slide to the left. In which
8. Watch the stage and slide (figure 19-4).
direction does the image move?
Turn the coarse adjustment so that the
c. Open and close the iris diaphragm.
How does this affect the image?
12. Without moving the body tube, turn the
revolving nosepiece until the high-
power objective is in place. Focus with
the fine adjustment only.
CAUTION: Watch the slide while turn-
ing the objectives to avoid breaking the
slide or objectives.
13. Under high power, make the following
observations:
a. How does the amount of light com-
pare with that needed under low
power? (You may need to adjust the
diaphragm for better viewing.)
b. Do you see a larger or a smaller area
of the object than was seen under
low power?
14. If the microscope has an oil-immersion
objective, do the following:
a. Turn the revolving nosepiece until
FIGURE 19-4 Watch the stage and slide the oil-immersion objective is in
while using the coarse adjustment to move the
position. Focus with fine adjustment
objective downward.
only.
PROCEDURE 19:1
CAUTION: Watch the slide while turn- 17. Use a damp, soft cloth to wipe the other
ing the objectives to avoid breaking the parts of the microscope.
slide or objectives.
18. Using the coarse adjustment, move the
b. Move the oil-immersion objective low-power objective so that it is in its
slightly to either side so that no objec- lowest position, down close to the
tive is in position. stage.
c. Place a small drop of immersion oil 19. Turn off the illuminating light.
on the part of the slide that will be
20. Place the cover back on the microscope.
directly under the objective.
This protects it from dust in the room.
CAUTION: Use the oil sparingly. The microscope can also be stored in a
dust-free cabinet.
d. Move the oil-immersion objective
back into position, taking care that CAUTION: Remember to place one
no other objective comes in contact hand on the arm and the other hand
with the oil. Make sure that the oil- under the base while moving the micro-
immersion objective is touching the scope.
drop of oil.
21. Make sure that the microscope is kept
e. Look through the eyepiece and use away from the counter’s edge. This pre-
the fine adjustment to bring the slide vents the microscope from being
into focus. knocked to the floor.
f. Move the diaphragm as necessary to 22. Clean and replace all equipment.
adjust the amount of light for view-
23. Remove gloves. Wash hands.
ing the slide.
g. When you are done viewing the slide,
turn the revolving nosepiece until the
low-power objective is in position.
CAUTION: Make sure no other objec-
tive comes in contact with the oil on the
slide. Practice
h. Use lens paper to carefully remove all Go to the workbook and use the
the oil from the oil-immersion objec- evaluation sheet for 19:1, Operating
tive. the Microscope, to practice this
15. When you are done viewing the slide, procedure. When you believe you
remove the slide and the coverslip. Wash have mastered this skill, sign the
and dry both items. sheet and give it to your instructor
for further action.
CAUTION: Handle both with care. They
break easily.
16. Use the special lens paper to clean the
eyepiece and the objectives.
CAUTION: Do not use any other mate- Final Checkpoint Using the criteria
rial to clean these parts. Towels, rags, listed on the evaluation sheet, your
and tissues can scratch these surfaces. instructor will grade your performance.
656 CHAPTER 19
ined by a qualified individual, and the organism

19:2 INFORMATION causing the disease is tentatively identified.
Other times, the specimen is placed or
Obtaining and Handling Cultures streaked on an agar plate, also called a culture
In some health careers, it may be necessary plate or petri dish, or in a culture media tube (fig-
for you to obtain a specimen of microorgan- ure 19-6). Agar is a special solid medium that pro-
isms, grow them on a culture medium, and stain vides both nourishment and moisture for the
a small sample. organism. The agar plate is placed in an incuba-
A culture specimen is obtained when a tor at 35–37°C for 24–36 hours, and the organism
doctor wants to identify the causative agent of a is grown. This is called culturing an organism. A
disease. The sample specimen is then either small sample of the cultured organism (called a
examined promptly or grown and examined for colony) is placed on a slide, stained, and then
identification. Specimens may be obtained from examined for identification. Exact identification
a variety of sites, including lesions on the skin or sometimes requires growing a sample of the cul-
from the eyes, ears, nose, throat, or other body tured organism (the colony) on another special
openings. A wide variety of collection containers medium, which helps differentiate the microor-
are available for obtaining and transporting cul- ganisms. In this manner, the organism can be
ture specimens (figure 19-5). The collection con- isolated.
tainer and swab used to collect the culture must In some instances, a culture and sensitivity
be sterile to prevent contamination from other (C&S) study is done. One method of performing a
sources. It is also important to select a container C&S is done using small, sterile disks containing
that has the proper medium for the type of cul- different antibiotics that are placed on the agar
ture obtained. The medium provides nourish- plate after the organism has been applied (figure
ment for the cultured organism and keeps it moist 19-7). If the organisms grow up to the edge of a
so that it can be examined. The specimen must particular disk, this means the organism is resis-
not be allowed to be in contact with any other tant to that antibiotic. The antibiotic would not
substances or objects once it has been obtained. work against the organism and would not help
Sometimes, the specimen is placed immedi- cure the disease. If the organisms do not grow
ately on a slide. This is called a direct smear, or close to the disk, this means the organisms are
bacteriological smear. The swab containing the sensitive to the antibiotic on the disk. This anti-
culture specimen is rolled across the surface of biotic would work against the organism and aid
the slide to place a thin film of culture material in the curing of the disease. In this manner, a doc-
on the slide. The smear is air dried and heat fixed, tor is better able to determine which antibiotic or
or passed through a flame, so the organisms will medication to give a patient for the disease or
adhere, or stick, to the slide. After the direct smear infection.
is stained so that organisms are visible, it is exam- After an organism has been grown in an agar
medium, a small sample can be transferred to a
FIGURE 19-5 A wide variety of collection contain-

ers are available for obtaining and transporting FIGURE 19-6 There are many different types of
culture specimens. agar plates and media tubes.
color at the end of the procedure is a gram-

positive organism.
2. Iodine is applied to the slide for approxi-
mately 1 minute. This solution sets the gen-
tian violet or crystal violet stain, or makes
the primary dye adhere to the organisms
on the slide.
3. A 95-percent solution of ethyl alcohol or an
acetone–alcohol decolorizer is applied to
the slide until the solution running off the
slide is no longer purple. This alcohol solu-
FIGURE 19-7 An agar plate prepared for a tion removes the purple color of the gen-
sensitivity study with small antibiotic disks posi- tian violet or crystal violet stain from
tioned on the plate. gram-negative organisms. Only gram-posi-
tive organisms retain the purple color after
slide so that it can be examined and identified. this step.
The slide must be stained with some type of dye
4. Safranin solution is applied to the slide for
so that the organism can be seen with a micro-
approximately 30–60 seconds. This solu-
scope. However, before the slide can be stained,
tion is a counterstain. It stains the gram-
the slide must be fixed. To fix a slide, it must be
negative organisms red so that they can be
held over a source of heat, such as a bunsen
seen under a microscope.
burner or alcohol lamp, for a very brief period of
time. The heat causes the organisms to stick to NOTE: Times may vary depending on the
the slide (figure 19-8). As a result, the organisms type of stain used. Read and follow the man-
will not wash off of the slide when various solu- ufacturer’s instructions.
tions or stains are applied to the slide.
After the slide is stained, organisms on the
A common technique for staining cultures is
slide are identified as gram positive if they retain
Gram’s stain. This staining technique not only
the purple color of the gentian violet or crystal
colors the organisms so that they are visible but
violet stain and gram negative if they retain the
also provides another method of identifying
red color of the safranin solution. A qualified lab
organisms. The Gram’s stain technique involves
technologist or physician examines the slide. By
the following four steps:
noting the shape of the organism and whether it
1. Gentian violet or crystal violet stain is is gram positive or negative, a preliminary identi-
applied to the slide for approximately 1 fication of the type of organism can be made.
minute. This is called the primary dye. It is Growing and isolating organisms on culture
purple. Any organism that keeps the purple plates does take time, usually 3–5 days. With cer-
tain types of infections, such as a streptococcus
throat infection, this delay can allow the organ-
isms to damage the heart valves and/or kidneys.
For this reason, rapid identification test kits have
been developed for many common bacterial infec-
tions. If streptococcus is identified by a rapid iden-
tification test, antibiotics that are effective against
streptococcus can be started immediately. The
rapid test systems are easy to use and have a high
level of accuracy, but the manufacturer’s instruc-
tions must be followed to eliminate false positives.
Most rapid tests also require that a positive and
negative control test be conducted at the same
time as the patient’s test to ensure accuracy.
FIGURE 19-8 The slide is fixed with heat so Because any culture may contain patho-
organisms will adhere (stick) to the slide. genic (disease-producing) organisms or be
658 CHAPTER 19
contaminated with blood and body fluids, stan- infectious-waste bag for disposal according to
dard precautions (see Chapter 14:4) must be legal requirements for infectious waste. Any lab
observed at all times while handling cultures. counter or contaminated area must be wiped
Hands must be washed frequently and thor- immediately with a disinfectant solution.
oughly, and gloves must be worn. Protective
clothing such as lab coats or lab aprons must be
worn. If splashing of specimens is possible, a STUDENT: Go to the workbook and complete
mask and protective eyewear must be worn. All the assignment sheet for 19:2, Obtaining and Han-
culture specimens and disposable equipment dling Cultures. Then return and continue with the
contaminated with the culture are placed in an procedures.
PROCEDURE 19:2A
6. Remove the sterile applicator from its
Obtaining a Culture package. Pick it up by the nonapplicator
Specimen end only. Make sure you do not touch the
sterile cotton tip to any surface or con-
Equipment and Supplies taminate it in any way (figure 19-9A).
CAUTION: If the tip does not remain
Sterile cotton applicator swabs, culture
sterile, the test will be inaccurate.
medium (some prepacked with sterile swabs),
sterile test tube with medium (if no prepacked 7. Place the sterile tip on the area to be
medium), label, pen or pencil for marking, cultured. Use a gentle yet firm rotating
disposable gloves, infectious-waste bag motion to cover the tip of the applicator
with a sample specimen (figure 19-9B).
Procedure 8. Remove the applicator from the culture
site. Be careful not to contaminate the
1. Check physician’s written order or tip.
obtain an order from your immediate
supervisor. 9. Place the applicator into the sterile tube
or culture-medium container (figure
2. Assemble equipment. 19-9C).
3. Wash hands. Put on gloves. CAUTION: Take care not to touch the
CAUTION: Observe standard precau- sides of the container, because the spec-
tions while obtaining and handling the imen will smear against the sides of the
culture specimen. If splashing of speci- container instead of being placed in the
mens is possible, a gown, mask, and eye medium.
protection must be worn. NOTE: Brace your arms against your
4. Introduce yourself. Greet and identify body to keep your hands steady while
the patient. Explain the procedure to inserting the applicator swab.
the patient. Obtain the patient’s con- 10. Check to be sure the tip is in the
sent. medium.
5. Check the body area where the speci- NOTE: This keeps the specimen sterile
men is to be obtained. The order should and moist for examination.
state the site for taking the specimen.
NOTE: Some culture-medium tubes
NOTE: Specimens can be taken from contain a liquid culture medium sepa-
the nose, throat, or other body areas, or rated from a gauze layer by a thin layer
from open wounds.
PROCEDURE 19:2A
FIGURE 19-9A Take care not to contaminate

the sterile tip as you remove the sterile applica-
tor from its package.
FIGURE 19-9C Take care not to touch the

sides of the culture container as you place the
applicator into the container.
FIGURE 19-9B Rotate the applicator tip to FIGURE 19-9D If the culture container has a
obtain a specimen from the site. separator, squeeze the container gently to
crush the glass and release the culture medium.
of glass or other material. To saturate
the gauze layer with the liquid medium,
it is necessary to squeeze the container
gently to break the glass or other mate-
rial (figure 19-9D). Read and follow the
manufacturer’s instructions when using
any culture-medium container.
11. Label the specimen with the patient’s
name, address, identification number,
doctor’s name, the date, the type of test
ordered, and the site from which the
specimen was obtained (figure 19-9E).
If a laboratory requisition form is
required, complete this form.
FIGURE 19-9E Label the culture specimen
12. Take or send the specimen to the labo- and/or laboratory requisition slip with all
ratory. If you will be transferring the required information.
660 CHAPTER 19
PROCEDURE 19:2A
specimen to a slide or an agar plate,
place the specimen in a safe location
until you are ready to use it. Keep it away
from direct sunlight and sources of Practice
heat. Go to the workbook and use the
13. Clean and replace all equipment. Place Obtaining a Culture Specimen, to
all contaminated disposable materials practice this procedure. When you
in the infectious-waste bag. Use a disin-
fectant to wipe the counter and any
contaminated areas.
14. Remove gloves. Wash hands thoroughly.

PROCEDURE 19:2B
CAUTION: Avoid contaminating the
Preparing a Direct applicator tip.
Smear 5. Use the thumb and forefinger of one
hand to pick up the clean slide. Hold it
Equipment and Supplies securely. The slide can also be placed on
a table or counter and held securely.
Culture specimen for direct smear, clean glass
slide, bunsen burner or alcohol lamp, stain- 6. Place the tip of the applicator swab con-
ing rack, rubber-tipped hemostats or slide taining the culture on the slide approxi-
clamps, disposable gloves, infectious-waste mately 1⁄2 inch away from the thumb
bag holding the slide.
7. Hold the applicator tip firmly on the
Procedure slide and roll it toward the opposite end
of the slide. Use firm, even pressure to
1. Assemble equipment. allow for the transfer of the organisms
2. Wash hands. Put on gloves. to the slide (figure 19-10). Stop 1⁄2 inch
from the end of the slide.
tions while handling any culture speci- 8. Allow the slide to dry at room tempera-
men. ture.
3. Clean the slide thoroughly. Avoid touch- CAUTION: If the slide does not dry prior
ing the top of the slide once it has been to being fixed, the heat from fixing the
cleaned. slide will drive the moisture out of the
organisms and distort their shape.
4. Carefully remove the specimen from the
medium tube. Handle the applicator by
the nonapplicator end only.
PROCEDURE 19:2B
CAUTION: Excess heat will shrink the
organisms, and they will no longer be
identifiable.
13. Place the slide on the staining rack; the
slide must be stained prior to being
viewed.
14. Label the slide with the patient’s name,
doctor’s name, address, identification
number, and any other necessary infor-
mation.
FIGURE 19-10 Roll the applicator tip across
the slide to transfer the organisms to the slide. 15. Clean and replace all equipment. Place
all contaminated disposable materials
9. Dispose of the contaminated applicator in the infectious-waste bag. Use a disin-
swab by placing it in an infectious-waste fectant to wipe the counter and any
bag. contaminated areas.
CAUTION: Handle the swab carefully to 16. Make sure the bunsen burner or alcohol
avoid infecting yourself or contaminat- lamp is extinguished.
ing other surfaces.
10. When the slide is dry, place it in a set of
rubber-tipped hemostats or slide
clamps. Make sure the smear side is fac-
ing upward.
11. Turn on the bunsen burner or alcohol
lamp.
CAUTION: If a match is used to turn on
Practice
the flame, extinguish the match and
then hold it under water before putting
it in a trash container. Preparing a Direct Smear, to
12. Hold the clamped slide 1–2 inches above believe you have mastered this skill,
the flame for 1–2 seconds. Do this three sign the sheet and give it to your
to four times. Do not get the slide too instructor for further action.
hot. Check the temperature by touching
the bottom of the slide lightly on your
hand. It should feel warm but not too
hot.
NOTE: This is called fixing. The heat Final Checkpoint Using the criteria
causes the organisms to stick to the listed on the evaluation sheet, your
slide. instructor will grade your performance.
662 CHAPTER 19
PROCEDURE 19:2C
Streaking an Agar
Plate
Agar plate with correct medium, specimen
for direct smear, label, pen or marker, incu-
bator, disposable gloves, infectious-waste
bag
Procedure
tions while handling any culture speci- FIGURE 19-11A Hold the agar plate firmly in
men. one hand while streaking it with the specimen.
3. Remove the applicator containing the of the tip so that all sides of the tip touch
culture specimen from its container. the agar, go from side to side approxi-
Hold it by the nonapplicator end. Take mately one-quarter of the way down the
care to avoid contaminating the appli- plate. To cover the second quadrant of
cator tip. Look at the tip to be sure it is the plate, turn the plate one-quarter
still moist. turn and repeat the side-to-side motion
of the applicator tip, crossing the first
NOTE: If the specimen is dry, the organ- quadrant two to three times. Turn the
isms have probably died, and the results plate one-quarter turn and use the same
will not be accurate. motion to cover the third quadrant. To
4. The agar plate is made up of two parts: cover the fourth quadrant, turn the plate
the lower disk, which contains the agar, one-quarter turn, and cross into the
and the upper lid. Open the agar plate. third quadrant one or two times. Note
Take care not to touch the inside of the the sample streaking pattern in figure
plate. Invert the lid; that is, place the lid 19-11B. This streaking method helps
with the top against the counter. In this 1st Streak
way, the inside of the lid faces up and
stays clean.
NOTE: The agar plate can also be placed
upside down, with the agar on top. The
agar plate should then be lifted. The lid
4th 2nd
will remain on the table, with the inside Streak Streak
facing up.
5. Hold the plate firmly in one hand (figure
19-11A) or place it on a flat surface.
6. Starting at the top of the agar, gently
place the applicator tip in one corner. 3rd Streak
Using a rotary motion, turning the top FIGURE 19-11B A sample streaking pattern.
PROCEDURE 19:2C
isolate the colonies of organisms in the is not available, use sterile thumb forceps.
fourth quadrant (figure 19-11C). Place the disks around the agar. Leave
spaces between the disks. Make sure that
NOTE: This is only one type of streaking
the disks are not too close to the edge of
pattern. Use the streaking pattern pre-
the agar plate (refer to figure 19-7).
ferred by your employer.
NOTE: The agar plate must be streaked
CAUTION: Be gentle. Do not break into
heavily and completely for a sensitivity
the agar.
study.
NOTE: An innoculating loop can also be
10. Pick up the agar plate lid by the side
used to streak the agar. After each quad-
edges. Take care not to touch the inside.
rant is streaked, the loop is placed in a
Place the lid on top of the agar plate.
flame and cooled. Use the method the
laboratory or physician prefers. NOTE: The agar plate can be placed into
the lid instead, but be careful not to
NOTE: Cover the agar only one time in
contaminate the insides.
each area. Do not go back over areas
already covered. 11. Label the bottom of the agar plate with
the patient’s name, doctor’s name,
7. Check to be sure all areas of the agar
address, identification number, date,
have been streaked. Different streaking
time, site of specimen, and other
methods can be used. Use the one the
required information.
laboratory or physician prefers.
12. Invert the agar plate and place it in the
8. Discard the applicator swab in the infec-
incubator at 35–37°C for 24–36 hours
tious-waste bag or a biohazard con-
(figure 19-11D). Be sure the plate is
tainer. Some laboratories require the
upside down with the agar on top. This
swab to be placed in a container of dis-
prevents moisture from settling on the
infectant prior to disposal in an infec-
agar.
tious-waste bag.
NOTE: The incubator provides darkness
9. If a sensitivity study is to be done, place
and warmth for growth of the organism.
antibiotic disks on the agar. You can use
The agar provides food and moisture to
an automatic dispenser of medicated
stimulate growth.
disks to do so. If an automatic dispenser
FIGURE 19-11C Note the isolated colonies of organisms in the fourth quadrant after the culture
has grown in the incubator.
664 CHAPTER 19
PROCEDURE 19:2C
13. Check the temperature of the incubator.
It is usually set at 35–37° Celsius (95–99°
Fahrenheit).
all contaminated disposable equipment
contaminated areas.
15. Remove gloves. Wash hands thoroughly
to prevent infection and spread of the
disease.
Practice
Streaking an Agar Plate, to practice
FIGURE 19-11D Invert the agar plate and
place it in the incubator for 24–36 hours at
35–37°C. Final Checkpoint Using the criteria
PROCEDURE 19:2D
Transferring Culture Procedure
from Agar Plate 1. Assemble equipment.
to Slide 2. Wash hands. Put on gloves.
Equipment and Supplies tions while handling any culture speci-
men.
Agar plate with growth, innoculating loop,
bunsen burner or alcohollamp, rubber-tipped 3. Light the bunsen burner or alcohol
hemostat or slide clamps, slide, normal saline lamp.
solution, staining rack, disposable gloves,
CAUTION: Wet the match before dis-
infectious-waste bag, pen or pencil
carding it in a trash can.
PROCEDURE 19:2D
4. Open the agar plate. Handle the outside 9. Place a small drop of normal saline on a
of the plate only. To prevent contamina- clean glass slide.
tion, place the lid with the top against
NOTE: Normal saline provides a liquid
the counter (that is, with the inside fac-
medium for the organisms.
ing up).
10. Mix the specimen (on the loop) and the
NOTE: The agar plate can also be placed
saline on the slide. This loosens the
upside down, with the agar on top. The
organisms and suspends them in liquid.
agar plate should then be lifted. The lid
will remain on the table, with the inside CAUTION: Do not rub the mixture
facing up. against the slide, because doing so could
damage the shape of the organisms.
5. Place the innoculating loop in the flame
until the loop end gets red hot. 11. Starting at one end of the slide, spread
the solution thinly over the slide. Cover
NOTE: This kills organisms that might
the entire width of the slide with the
be present on the loop.
culture.
6. Cool the loop by dipping it into an area
12. Place the slide on the staining rack to
of agar that has no organisms present.
air-dry. Fix as previously taught.
NOTE: A hot loop will destroy the shape
13. Place the loop in the flame until red hot.
of the organisms, making them uniden-
This destroys all organisms.
tifiable.
14. Label the slide with the patient’s name,
7. Dip the loop into a small portion of the
doctor’s name, address, identification
colony growth (figure 19-12). Skim the
number, and other required informa-
top of the growth to get some organisms
tion.
on the loop.
NOTE: Only a small sample is needed. If
all contaminated disposable equipment
too large a mass is obtained, the slide
will be too concentrated.
8. Immediately place the lid on the agar contaminated areas.
plate to prevent contamination to your-
self or the environment from the organ-
ism.
Practice
Transferring Culture from Agar
Plate to Slide, to practice this
for further action.
FIGURE 19-12 Dip the loop into a small Final Checkpoint Using the criteria
portion of an isolated growth of the cultured listed on the evaluation sheet, your
organism. instructor will grade your performance.
666 CHAPTER 19
PROCEDURE 19:2E
CAUTION: Avoid touching the top of the
Staining with Gram’s slide with your fingers.
Stain 4. Cover the slide with gentian violet or
crystal violet stain (figure 19-13). Leave
Equipment and Supplies the stain in place for the recommended
time, usually 1 minute. Stain only the
Slide with fixed smear, staining rack, gentian
smeared side of the slide. This is the pri-
violet or crystal violet stain, Gram’s iodine,
mary dye.
95-percent ethyl alcohol or acetone–alcohol
decolorizer, safranin solution, distilled water, NOTE: To avoid staining the sink, it is
asepto syringe or plastic squeeze bottle, dis- best to let water run during the entire
posable gloves, infectious-waste bag procedure.
NOTE: Timing may vary with types of solu- NOTE: The primary stain is purple and
tions used. Read the instructions provided will dye all gram-positive organisms.
with the solutions or follow agency policy. Thus, any organisms that remain purple
at the end of this procedure are gram-
Procedure positive organisms.
5. Rinse the slide thoroughly with distilled
1. Assemble equipment. water. Use an asepto syringe or plastic
2. Wash hands. Put on gloves. squeeze bottle to rinse gently.
CAUTION: Observe standard precautions 6. Use Gram’s iodine solution to cover the
while handling any culture specimen. slide. Tilt the slide to allow the iodine
and remaining water to run off. Then,
3. Use your thumb and forefinger to pick
cover the slide again with iodine. Leave
up the fixed slide. Place the slide on the
in place for the recommended time,
staining rack. Check to be sure the smear
usually 1 minute. This sets the primary
side is facing up.
1. Gentian or 60 sec. 2. Wash 2 sec. 3. Gram’s 60 sec. 4. Decolorize Until run-off

Crystal iodine with alcohol is clear
violet (3 to 5 sec.)
5. Wash 2 sec. 6. Safranin 30 to 60 sec. 7. Wash 2 sec. 8. Blot back of slide dry.
FIGURE 19-13 The Gram’s stain technique.

PROCEDURE 19:2E
dye. organisms red so that they can be seen
and identified under a microscope.
NOTE: The first application of iodine is
allowed to run off the slide so that the 11. Use distilled water to rinse the slide.
second application will result in a full-
12. Use a paper towel to dry the back of the
strength iodine covering.
slide. Do not dry the front, or smear, side
NOTE: Any gram-positive organisms because rubbing it can remove the
will now have the purple primary dye smear from the slide. Allow the front of
set into them. After this step, gram-neg- the slide to air-dry.
ative organisms will also be dyed purple.
13. Once dry, the slide is fairly permanent
This dye must be removed.
and is ready for microscopic examina-
7. Use an asepto syringe or plastic squeeze tion. A laboratory technologist or doctor
bottle to rinse the slide thoroughly with can examine the slide and identify the
distilled water. type of organism present by noting
the shape and color. If purple, the organ-
8. Use 95-percent ethyl alcohol or acetone–
ism is gram-positive; if red, it is gram-
alcohol to decolorize the slide. Apply
negative.
the alcohol to the slide. Immediately tilt
the slide to allow the decolorizer to run 14. Clean the area thoroughly. Replace all
off. Reapply the alcohol and again tilt equipment.
the slide to allow the alcohol to run off.
NOTE: The dyes can permanently stain
After each application, check the color
the counter if not removed immedi-
of the alcohol as it runs off the slide.
ately.
Stop immediately when the decolorizer
is no longer purple. This usually occurs 15. Remove gloves. Wash hands.
in 3–5 seconds.
NOTE: This step removes the primary
dye from the gram-negative organisms.
Only the gram-positive organisms
remain purple.
CAUTION: This is a crucial step. Too
many applications of alcohol can also Practice
decolorize gram-positive organisms. Go to the workbook and use the
Stop as soon as the alcohol is no longer evaluation sheet for 19:2E, Staining
purple. with Gram’s Stain, to practice this
9. Rinse the slide well with distilled water
to remove any remaining decolorizer.
10. Use safranin solution to counterstain for further action.
the slide. Apply the safranin, tilt the slide
to allow the safranin and remaining
water to run off, and then reapply the
safranin. This stain should remain on
the slide for the recommended time, Final Checkpoint Using the criteria
usually 30–60 seconds. listed on the evaluation sheet, your
NOTE: Safranin stains gram-negative
668 CHAPTER 19
19:3 INFORMATION
Puncturing the Skin to Obtain
Capillary Blood
Blood tests are often done to assist a physi-
cian in making a diagnosis. Depending on
your chosen health career, you may be responsi-
ble for performing some basic blood tests. Blood
must be obtained to do these tests. This section
provides basic facts on performing a skin punc-
ture to obtain blood. No procedures should be
attempted without classroom instruction and
FIGURE 19-14 Only legally qualified individuals
supervision.
should perform a venipuncture to obtain blood.
Blood for testing can be obtained in various
(Courtesy of Centers for Disease Control and
ways. For many routine tests, a simple skin Prevention Public Health Image Library/Jim
puncture provides a sufficient amount of blood. Gathany)
Skin punctures are used only for tests requiring
small quantities of blood. This blood is obtained A.
from the capillaries and is often called peripheral
blood. For other tests requiring larger quantities
of blood, a venipuncture is performed. In a
venipuncture, the blood is taken from a vein. For
still other tests, blood is taken from an artery.
Arterial blood is used for specific tests such as
those that measure the amount of blood gases Earlobe
(oxygen and carbon dioxide) or determine acid– Infant’s heel/ Ring/great finger
base balance. great toe
Responsibility for obtaining blood for vari-
ous blood tests varies. Liability should be B.
checked for individual states. In some states, Correct Incorrect
health occupations students are not permitted to
perform any procedure involving obtaining blood.
It is vital that you determine what you are legally
permitted to do.
The procedure that follows discusses only the
skin puncture. If you are required to do a veni-
puncture or to draw arterial blood, you need spe-
FIGURE 19-15 (A) Common skin puncture sites
cific training in these procedures. Only legally for obtaining capillary blood. (B) Skin punctures
qualified individuals should perform venipunc- should be made across the grain of lines in the
tures and arterial punctures (figure 19-14). finger.
Careful aseptic technique must be followed
while performing a skin puncture. The skin must ture is performed, care must be taken in the selec-
be cleaned thoroughly with 70-percent isopropyl tion of the finger. The thumb, index finger, or
alcohol or a similar antiseptic. The lancet used to pinkie finger should not be used because they
puncture the skin must be sterile. Finally, the have arteries close to the surface. In addition,
puncture site should be covered with sterile gauze they are used most frequently, and the chance for
after the skin puncture is complete. infection is greater. The finger to be used must be
Common puncture sites used to obtain capil- examined closely. Avoid fingers with edema
lary blood include the fingers, heels, and ear lobes (swelling), callouses, scars, rashes, or sores. Make
(figure 19-15A). The heel is frequently used for sure the skin is warm and pink. If the finger is
infants until they learn to walk. A finger is usually cyanotic (blue), do not use it. Cyanosis indicates
used for children and adults. When a finger punc- poor circulation.
The skin puncture should be 2–4 millimeters titis B (HBV), hepatitis C (HCV), and acquired
deep to reach the capillary beds under the skin. immune deficiency syndrome (AIDS), can be
The puncture should be made across the grain of transmitted by blood. Hands must be washed
lines in the finger, or at right angles to the finger- thoroughly and gloves must be worn at all times.
print striations (figure 19-15B). This type of punc- If splashing of the blood is possible, masks, pro-
ture heals more rapidly in most cases. tective eyewear, and gowns must also be worn.
The first drop of blood obtained is always Any blood spills must be wiped up immediately
removed. It is contaminated with alcohol, perspi- with a disinfectant solution. All contaminated
ration, excess tissue fluid, and other substances disposable materials or supplies and any remain-
on the skin that can dilute the blood and cause ing blood samples are placed in an infectious-
inaccurate test results. The second or succeeding waste bag prior to being disposed of as
drops of blood can be used for the various blood infectious-waste according to legal requirements.
tests. Any sharps, such as lancets or needles, must be
After performing a skin puncture, the health placed in a leakproof puncture-resistant sharps
care worker must remain with the patient until box. They should not be bent, broken, or recapped.
the blood stops flowing. When sufficient blood It is important for the health care worker to
has been obtained, sterile gauze should be held observe all precautions established by his or her
firmly against the puncture for at least 1–3 min- agency for workers who handle blood samples.
utes. If the patient is taking an anticoagulant, a All blood must be regarded as hazardous, because
medication such as aspirin or Warfarin sodium many illnesses can be transmitted through
(Coumadin) that prevents clotting of the blood, improper handling of blood samples.
pressure should be held against the puncture site
for at least 3–5 minutes to help stop the bleeding. STUDENT: Go to the workbook and complete
Standard precautions (Chapter 14:4) must the assignment sheet for 19:3, Puncturing the Skin
be observed at all times while obtaining and to Obtain Capillary Blood. Then return and con-
handling blood. Many diseases, including hepa- tinue with the procedure.
PROCEDURE 19:3
Puncturing the Skin to Explain the procedure. Obtain the
Obtain Capillary Blood patient’s consent.
NOTE: It is usually best to seat the
Equipment and Supplies patient in a comfortable position.
Sterile lancet, 70-percent isopropyl alcohol, 4. Select a finger. Make sure it is free from
sterile gauze pads, disposable gloves, mask, edema, cyanosis, scars, sores, and cal-
protective eyewear, gown, sharps box, louses. Do not use the thumb, index fin-
infectious-waste bag ger, or pinkie finger. If the hand and
fingers are cold to the touch, wrap them
Procedure in a warm cloth or hold them under
warm water for a few minutes to stimu-
1. Assemble equipment. late circulation.
2. Wash hands. Put on gloves. If splashing NOTE: Check the circulation in the fin-
of blood is possible, put on a gown, face ger. The finger should be warm and pink
mask, and protective eyewear. for good blood supply. Check the color
of the nail bed.
CAUTION: Observe all standard precau-
tions while obtaining and testing blood.
670 CHAPTER 19
PROCEDURE 19:3
NOTE: Although this procedure de-
scribes a finger puncture, the same prin-
ciples should be observed when using
any skin site to obtain capillary blood.
5. Cleanse the finger thoroughly with a
sterile alcohol swab or a sterile gauze
pad saturated with 70-percent isopropyl
alcohol. Allow the area to air-dry.
NOTE: Do not allow the finger to touch
anything.
6. Grasp the finger firmly with your thumb
and forefinger. Hold the sterile lancet in
the other hand. Use a quick, clean, stab-
bing stroke to puncture the finger with FIGURE 19-17A To use an automatic lancet
device, position the lancet over the skin and
the sterile lancet (figure 19-16). Make
depress the plunger to make the puncture.
the cut at right angles to the fingerprint
(Courtesy of Becton Dickinson VACUTAINER
striations, near the top of the finger but
Systems)
not too close to the fingernail.
NOTE: The puncture should be 2–4 mil-
limeters deep.
NOTE: Many agencies use automatic
lancet devices. The lancet is positioned
over the skin site and activated to allow
the lancet to puncture the skin (figure Image not available due to copyright restrictions
19-17A). Most manufacturers produce
color-coded lancets that puncture the
skin to different depths (figure 19-17B).
Read and follow manufacturer’s instruc-
tions when using an automatic device.
CAUTION: Do not squeeze or milk the

finger because doing so will cause tissue
fluid to mix with the blood. If necessary,
use gentle pressure at a distance from
the puncture site to start the blood
flow.
check the puncture to be sure it is at a
correct angle and is free flowing.
7. Immediately place the lancet in a punc-
ture-resistant sharps container. Do not
FIGURE 19-16 A sterile lancet is used to bend or break the lancet before discard-
puncture the skin 2–4 millimeters deep. ing it.
PROCEDURE 19:3
8. Use sterile gauze to remove the first 11. Clean and replace all equipment. Put all
drop of blood. This blood is contami- contaminated disposable supplies in
nated with alcohol, perspiration, and the infectious-waste bag. Use a disin-
other substances from the skin that can fectant to wipe the counter and any
dilute the blood and cause inaccurate contaminated equipment.
test results. Discard the gauze in the
12. Remove gloves and discard in an
infectious-waste bag.
infectious-waste bag. Wash hands thor-
9. Use the second and succeeding drops of oughly.
blood to perform the blood tests ordered
(for example, hemoglobin). Work quickly
to avoid cessation of bleeding.
10. When sufficient blood has been
Practice
obtained, instruct the patient to hold Go to the workbook and use the
sterile gauze firmly against the puncture evaluation sheet for 19:3,
for at least 1–2 minutes. Puncturing the Skin to Obtain
Capillary Blood, to practice this
CAUTION: If the patient is taking an procedure. When you believe you
anticoagulant, pressure should be held have mastered this skill, sign the
against the puncture site for at least 3–5 sheet and give it to your instructor
minutes.
for further action.
CAUTION: Remain with the patient
until the bleeding stops. You must be Final Checkpoint Using the criteria
certain that bleeding has stopped before listed on the evaluation sheet, your
you leave the area. instructor will grade your performance.
Several different methods can be used to per-

19:4 INFORMATION form an Hct. A popular method is the microhe-
matocrit. This test requires less blood and can be
Performing a Microhematocrit done in a shorter period of time compared to
One of the basic blood tests you may be other methods. A special centrifuge is used for
required to perform is the microhematocrit. the microhematocrit. This machine spins the
A hematocrit (Hct) or “crit,” is a blood test that blood tubes at approximately 10,000 revolutions
measures the volume of packed red blood cells per minute with a centrifugal (driving away from
(RBCs), or erythrocytes, in the blood. It is often the center) force. The force separates the blood
described as a measurement of the percentage of into three main layers: RBCs, a buffy coat, and
RBCs per volume of blood. Erythrocytes are the plasma (figure 19-18). The buffy coat is a very
blood cells that carry oxygen from the lungs to thin, whitish layer consisting of white blood cells
the body cells. They also carry carbon dioxide (WBCs) and platelets. Leukocytes (white blood
from the body cells to the lungs, where it is elimi- cells or WBCs) are important for fighting infec-
nated from the body. A normal count for erythro- tions in the body. The normal count for leuko-
cytes (red blood cells) is 4.5–5.5 million per cubic cytes is 5,000–9,000 per cubic millimeter of blood.
millimeter of blood. Most erythrocyte counts are Leukocyte counts can be performed manually or
performed on computerized cell counters. Man- by a computerized cell counter. However, the
ual counts can be performed, but they are diffi- buffy coat can provide an estimate of the number
cult to do accurately. For this reason, hematocrit of leukocytes because each 0.1 millimeter (mm)
(Hct) and hemoglobin (Hgb) tests are used much thickness of the buffy coat equals approximately
more frequently to determine the status of the 1,000 WBCs. A thickness of 0.6 mm would equal
erythrocytes in the blood. approximately 6,000 WBCs, and a thickness of
672 CHAPTER 19
Capillary tube
Plasma
Buffy coat
Red blood cells
Sealing clay
FIGURE 19-18 The microhematocrit centrifuge

separates the blood into three main layers: erythro-
cytes (red blood cells), a buffy coat, and plasma.
1 mm would equal approximately 10,000 WBCs. A

graphic reading device on the microhematocrit
centrifuge is used to measure the depth of the
buffy coat and the percentage of RBCs (figure
19-19). If the centrifuge does not have a graphic
FIGURE 19-19 By using the graphic reading
device on the microhematocrit centrifuge, the
reading device, the manufacturer will provide a
percentage of erythrocytes (red blood cells) can be
reader card to obtain the correct measurements. measured.
Follow the manufacturer’s in-structions to use
the reader card.
Special capillary tubes are used in the micro- averaged to determine the specific hematocrit
hematocrit centrifuge. The tubes are usually lined (Hct) of a patient. For example, if one tube regis-
with an anticoagulant such as heparin. An anti- ters at 41 percent and the second tube registers at
coagulant is a substance that prevents the blood 44 percent, the two numbers are added together:
from clotting. The tubes are filled to the indicated
level with blood from a free-flowing skin punc- 41 44 85
ture. The empty (that is, without blood) ends of The total is divided by 2 to obtain the average:
the tubes are sealed with special plastic sealing
42.5
clay (figure 19-20). This clay keeps the blood from
2√85.0
running out of the tube during centrifuging.
8
Extreme care must be taken to avoid contaminat-
05
ing the clay block with the blood. Self-sealing
4
tubes are available for use. These tubes contain a
10
plug with a small air channel to allow air to escape
10
when blood is drawn into the tube. When the
0
blood touches the plug, the air channel seals
automatically. The Hct reading for the two tubes would be
In some agencies, two tubes are filled for the recorded as 42.5 percent. In other agencies, one
test and the readings of the two tubes are tube is used to obtain the Hct reading for a
the total blood volume is RBCs in female individ-

uals, and 40–55 percent of the total blood volume
in male individuals is RBCs. Newborns have a
value of 51–61 percent, children 1 year old aver-
age 32–38 percent, and children 6 years old aver-
age 34–42 percent.
A low hematocrit often indicates anemia. A
high hematocrit reading can indicate polycythe-
mia. Anemia is a low number of RBCs, and poly-
cythemia is a high number of RBCs. Because
there are several different types of each of these
conditions, the physician usually conducts other,
more extensive blood tests to evaluate the condi-
tion. Patients with burns or dehydration can also
have a high hematocrit level but their red blood
cell counts will be normal. Patients with severe
bleeding may have a low hematocrit level.
Accuracy is essential while performing this
test because the test is used to diagnose disease.
False results can lead to improper diagnosis and
care.
CAUTION: If any results are questionable,
do not hesitate to repeat the test.
FIGURE 19-20 The empty end of the capillary Careful recording of the test is also essential.
tube is sealed with clay to prevent the blood from Hematocrit is often abbreviated Hct. The record-
running out of the tube during centrifuging. ing of a test might look like this: Hct. 35%.
Double-check all readings to make sure they are
accurate.
patient. The reading obtained from the single It is the physician’s responsibility to report
tube is recorded as the Hct percentage. the results of this test to the patient.
Normal values for the test vary slightly
depending on the types of microhematocrit cen- STUDENT: Go to the workbook and complete
trifuge and capillary tube used. An average value the assignment sheet for 19:4, Performing a Micro-
for adults is 35–45 percent for women and 40–55 hematocrit. Then return and continue with the
percent for men. In other words, 35–45 percent of procedure.
PROCEDURE 19:4
NOTE: The following procedure is for the
Performing a Readacrit centrifuge. Follow specific manu-
Microhematocrit facturer’s instructions when using other
equipment.
Procedure
Sterile lancet, alcohol swabs, microhemato-
crit capillary tubes, microhematocrit centri- 1. Assemble equipment (figure 19-21A).
fuge, capillary tube, sealing clay (if the tube is
not self-sealing), sterile gauze, disposable 2. Wash hands. Put on gloves. If splashing
gloves, mask, protective eyewear, gown, of blood is possible, put on a gown, face
sharps container, infectious-waste bag, paper, mask, and protective eyewear.
pen or pencil
674 CHAPTER 19
PROCEDURE 19:4
FIGURE 19-21A Equipment for a micro-

hematocrit. FIGURE 19-21C Immediately put the used
lancet into the sharps container.
Explain the procedure. Obtain the
NOTE: It is best to seat the patient in a
comfortable position.
4. Perform the procedure for a skin punc-
ture (figure 19-21B). Put the used lancet
in the sharps container immediately FIGURE 19-21D Allow a second well-
(figure 19-21C). rounded drop of blood to form at the puncture
5. Use sterile gauze to remove the first site.
drop of blood. Discard the gauze in the
6. Allow a second well-rounded drop of
blood to form at the puncture site (fig-
ure 19-21D). Hold the capillary tube at a
slight angle to the skin. Place the end
without the indicator mark into the drop
FIGURE 19-21E Hold the capillary tube at a

slight angle to the skin to fill the tube with blood to
the indicator mark.
of blood (figure 19-21E). Do not touch

the skin. Allow the blood to flow into the
tube until it reaches the indicator mark.
FIGURE 19-21B Perform a skin puncture to Check to make sure there are no air
obtain capillary blood. bubbles in the tube.
PROCEDURE 19:4
NOTE: If the tube does not have an indi-
cator mark, fill it to within 2 millimeters
of the end, or approximately three-
quarters full.
CAUTION: Do not use blood that has
started to clot.
7. Hold a gloved finger over the end of the
tube to prevent the blood from flowing
out. Seal the opposite end (the one with- FIGURE 19-21F Place the sealed end of the
out blood) by tapping the tube into a capillary tube against the rubber buffer on the
tray of sealing clay (refer to figure 19- outer edge of the microhematocrit centrifuge.
20). Check the seal to be sure there are
no openings. If a self-sealing tube is
NOTE: Read specific manufacturer’s
used, check to make sure that the plug
instructions regarding loading the cen-
has expanded to close the air channel
trifuge.
and seal the tube.
CAUTION: Handle tubes carefully to
CAUTION: Avoid applying pressure
avoid breakage.
while sealing the tube because the tube
may break. NOTE: Check to be sure the tube is in
the correct slot.
8. If your agency requires two capillary
tubes for the test, fill and seal the sec- 11. Lock the centrifuge cover by turning it
ond tube. to the marked angle. Be sure the outside
lid is also securely closed. Set the timer
to the recommended time (usually 3–5
obtained, instruct the patient to hold
minutes) and turn the machine on.
sterile gauze firmly against the puncture
for at least 1–2 minutes. CAUTION: Recheck the lids. If they are
not secure, the tube could fly out.
CAUTION: If the patient is taking an
anticoagulant, pressure should be held 12. When spinning stops completely, open
against the puncture site for at least 3–5 the lid. Push the tube upward so the top
minutes. of the clay line is at zero. Read the num-
ber at the top of the RBC layer (figure
CAUTION: Remain with the patient
19-21G).
until the bleeding stops.
NOTE: Remember that three layers are
10. Place the tube into the microhematocrit
present in the tube. The lower layer is
centrifuge. Make sure the tube end with
RBCs; the middle layer is a thin, buffy
the clay seal is against the rubber buffer
coat of WBCs and platelets; and the top,
(figure 19-21F). The open end of the
clear layer is plasma (refer to figure 19-
tube should face the center of the cen-
18).
trifuge. If slots are designated for male
or female, place the tube in the correct NOTE: If you are using a centrifuge with-
slot. If one tube is used, many manufac- out a built-in scale, carefully remove the
turers recommend placing an empty tubes from the centrifuge. Position the
tube in the opposite slot to balance the tubes on the microhematocrit reader
centrifuge. If two tubes are used, they card provided by the manufacturer. Fol-
can be placed on opposite sides. low the manufacturer’s instructions to
676 CHAPTER 19
PROCEDURE 19:4
16. Clean and replace all equipment. Put
the capillary tube(s) in the sharps con-
tainer. Place any contaminated dispos-
able supplies in the infectious-waste
bag. Use a disinfectant to wipe the cen-
trifuge, the counter, and any contami-
nated areas.
oughly.
patient’s chart or the agency form, for
FIGURE 19-21G After positioning the tube so
example: date; time; Hct: 45%; and your
the top of the clay line is at zero, read the
percentage number at the top of the red blood
signature and title. Report any abnor-
cell layer. mal readings immediately.
read the correct value for the hemato-

crit. Practice
13. Double-check the accuracy of your Go to the workbook and use the
reading. If two tubes are used, obtain a evaluation sheet for 19:4,
reading for each of the tubes. Add the Performing a Microhematocrit, to
two readings together. Divide the sum practice this procedure. When you
by 2. This number is the hematocrit believe you have mastered this skill,
reading. sign the sheet and give it to your
NOTE: The final reading for two tubes is instructor for further action.
an average reading of both tubes.
14. Record your reading.
15. Check the patient to be sure bleeding listed on the evaluation sheet, your
from the puncture has stopped. instructor will grade your performance.
oxygen and transports it to the body cells. Hemo-

19:5 INFORMATION globin also assists in carrying carbon dioxide
from the body cells to the lungs.
Measuring Hemoglobin Before hemoglobin concentration can be
Another blood test you may be required to per- determined, the blood must be hemolyzed.
form is the hemoglobin test. Various methods are Hemolysis is the destruction of RBCs. When
used to perform this test. Using a hemoglo- RBCs are destroyed, the hemoglobin is released
binometer is one method. into the solution that surrounds the cells. Whole
The hemoglobin (Hgb) test is used to blood is normally red and cloudy in appearance.
determine the oxygen-carrying capacity of When the cells rupture during hemolysis and
the blood. Hemoglobin is a substance found in hemoglobin is released, however, the blood
red blood cells (RBCs). It is composed of two becomes clear, or transparent. Hemolysis solu-
parts: heme, an iron-containing portion, and glo- tions contain special chemicals that cause this
bin, a protein. The hemoglobin combines with reaction outside the body.
The hemoglobinometer is a special instrument the blood and releases the hemoglobin. The
used to measure the hemoglobin concentration cuvette with the hemolyzed blood sample is then
in blood (figure 19-22). The hemoglobinometer is placed in the photometer, which automatically
used with an offset chamber and hemolysis stick. measures the color intensity. This test is more
Blood is placed on the chamber, and the hemo- accurate because it does not depend on an indi-
lytic stick is used to hemolyze the blood sample. vidual’s ability to compare color intensities. For
A coverclip is lowered over the hemolyzed blood accurate readings, it is important to read and fol-
specimen, and the chamber is inserted into the low the instructions provided by the manufac-
hemoglobinometer for a reading. By using a color turer of the photometer.
comparison, an approximate reading for an indi- Normal values for hemoglobin vary with the
vidual patient can be obtained. This test is not as type of test. An average range is 12–18 grams of
accurate as other types of hemoglobin tests hemoglobin per 100 milliliters of blood. Males
because it relies on the ability of the human eye average 13–18 grams, females average 12–16
to perform a color match. grams, newborns average 16–23 grams, and chil-
An automated photometer can also be used to dren from 1–10 years of age average 10–14 grams
check the level of hemoglobin. A disposable of hemoglobin per 100 milliliters of blood.
cuvette, or microcuvette, filled with a hemolyzing A low hemoglobin level can indicate anemia.
solution, is used to obtain a blood sample. The A high level can indicate polycythemia, which is
hemolyzing solution in the cuvette hemolyzes characterized by high hemoglobin concentration
and number of RBCs.
Accuracy is essential while performing this
test. Care must be taken to follow the procedure
exactly. The reading should be double-checked.
If any results are questionable, the test should be
repeated.
It is the physician’s responsibility to report
the results of this test to the patient.

FIGURE 19-22 The hemoglobinometer is a the assignment sheet for 19:5, Measuring Hemo-
special instrument used to measure the hemoglobin globin. Then return and continue with the proce-
concentration in blood. dure.
PROCEDURE 19:5A
Measuring Procedure
Hemoglobin with a 1. Assemble equipment.
Hemoglobinometer 2. Wash hands. Put on gloves. If splashing
of blood is possible, put on a gown, face
Equipment and Supplies mask, and protective eyewear.
Sterile lancet, alcohol swab, sterile gauze
pads, hemoglobinometer, blood chamber,
hemolysis applicator sticks, lens paper, dis- 3. Use lens paper to clean the blood
posable gloves, mask, eye protection, gown, chamber.
sharps container, infectious-waste bag, paper,
pencil or pen
678 CHAPTER 19
PROCEDURE 19:5A
NOTE: Lens paper prevents scratches hemolysis solution (the end shiny in
on the chamber. appearance). This usually takes 30–45
seconds, but it is best to observe the
appearance of the blood rather than
Explain the procedure to the patient.
depend on the time factor. The blood
Obtain the patient’s consent.
will look red and cloudy at the start and
5. Perform a skin puncture. Put the used then become clear, or transparent, when
lancet in the sharps container immedi- it is hemolyzed.
ately.
NOTE: This procedure ruptures the
6. Wipe off the first drop of blood. Use the walls of the blood cells. The hemoglobin
second well-rounded drop. Place a large goes into a uniform solution, which is
drop of blood on the clean chamber transparent.
(figure 19-23A). Avoid touching the
CAUTION: Make sure the entire sample
chamber with the patient’s skin.
of blood is completely hemolyzed.
CAUTION: The first drop of blood is not
9. Use the cover glass to cover the cham-
used because it is diluted and contami-
ber; push the chamber and coverglass
nated and can cause inaccurate test
into the clip. The chamber is now ready
results.
to use.
10. Look into the hemoglobinometer. Check
obtained, instruct the patient to hold
the lighting to make sure it is equal in
sterile gauze firmly against the puncture
the entire field. If one side is darker,
site for at least 1–2 minutes.
inform your instructor.
CAUTION: An exact color match is
anticoagulant, pressure should be held
essential to be sure the hemoglobinom-
against the puncture site for at least 3–5
eter is calibrated correctly. An incorrect
minutes.
calibration will result in inaccurate
CAUTION: Remain with the patient readings. Follow manufacturer’s instruc-
until the bleeding stops. tions to calibrate the device.
8. Use the hemolysis applicator stick to NOTE: Many agencies use a quality-
hemolyze the blood (figure 19-23B). Use control test chamber with a prede-
a rotating motion to agitate the blood. termined hemoglobin reading. The
Use the end of the stick that has the chamber is placed into the hemoglo-
FIGURE 19-23A Place a large drop of blood FIGURE 19-23B Use the hemolysis applica-
on the glass chamber, taking care not to touch tor stick to hemolyze the blood until it is clear or
the chamber with the patient’s skin. transparent.
PROCEDURE 19:5A
binometer, the technician performs a 15. Recheck your reading to be sure it is
color match, and the reading is checked. accurate.
If the reading is not the same as the pre-
16. Check the patient to be sure the skin
determined reading for the test cham-
puncture has stopped bleeding.
ber, the hemoglobinometer should not
be used. In some cases, the technician 17. Clean and replace all equipment. Wash
needs additional training to perform a the chamber and coverglass, and then
correct color match. wipe with a disinfectant solution. Some
agencies require that the glass be soaked
11. Slide the loaded chamber into the
in a disinfectant. Dry it with lens paper
hemoglobinometer (figure 19-23C).
to prevent scratches. Use a disinfectant
CAUTION: Avoid applying force when solution to wipe off the outside of the
loading the chamber because the cham- hemoglobinometer. Place all contami-
ber may break. nated disposable materials in the infec-
tious-waste bag. Use a disinfectant to
12. Look into the eyepiece. Use your thumb
wipe the counter and any contaminated
to turn on the light. Slide the slide but-
areas.
ton until the two halves of the field are
equally light and appear as a single field 18. Remove gloves and discard in an infec-
of the same color. tious-waste bag. Wash hands thor-
oughly.
check the color match. 19. Record the required information on the
13. Read the scale to determine the number
example, date; time; Hgb: 14.5 gm; and
of grams per 100 milliliters of blood. The
reading will be 12, 12.5, 13, or a similar
abnormal readings immediately.
number.
NOTE: Normal values for hemoglobin
are 12–18 grams per 100 milliliters of
blood.
14. Record your reading as in the following
example: Hgb 12 gm.
Practice
Measuring Hemoglobin with a
Hemoglobinometer, to practice this
for further action.
FIGURE 19-23C Slide the loaded chamber Final Checkpoint Using the criteria
into the slot on the side of the hemoglobinom- listed on the evaluation sheet, your
eter. instructor will grade your performance.
680 CHAPTER 19
PROCEDURE 19:5B
card provided with the unit. The
Measuring value displayed should not be more
Hemoglobin with a than ±0.3gm/dL from the value on
the control cuvette card. If the value
Photometer is within this range, the photometer
is calibrated correctly.
Equipment and Supplies CAUTION: If the photometer is not cali-
Sterile lancet, alcohol swab, sterile gauze brated correctly, notify your instructor
pads, hemoglobin photometer, control or refer to the troubleshooting guide in
cuvette, disposable cuvette, tissue or lens the manual provided with the photom-
paper, disposable gloves, mask, eye protec- eter. Do not use the photometer if the
tion, gown, sharps container, infectious- calibration is not correct. Inaccurate test
waste bag, paper, pencil or pen results would be obtained.
NOTE: This procedure describes the use of 4. Introduce yourself. Identify the patient.
the HemoCue Hemoglobin Photometer. Explain the procedure to the patient.
Obtain the patient’s consent.
Procedure 5. Perform a skin puncture. Put the used
lancet in the sharps container immedi-
1. Assemble equipment. Read manufac- ately.
turer’s instructions provided with the
photometer. 6. Wipe off the first and/or second drop of
blood. Use the second or third drop. Use
2. Wash hands. Put on gloves. If splashing your gloved index finger and thumb to
of blood is possible, put on a gown, face hold the cuvette at the square end (fig-
mask, and protective eyewear. ure 19-24A). Place the angled tip end
CAUTION: Observe all standard precau- into the middle of the drop of blood (fig-
tions while obtaining and testing blood. ure 19-24B). Hold the cuvette steady to
allow capillary action to completely fill
3. Check the photometer to make sure it is
the cavity at the tip end with blood.
calibrated correctly:
Check the filled cuvette to make sure no
a. Press the power button to turn the air bubbles are present in the optical
photometer on.
b. Pull out the cuvette holder to the load
position. The display will show the WING
letters Hb.
SQUARE END
c. When the indicator displays Ready,
insert the red control cuvette into the
cuvette holder. Gently push the OPEN
END
holder into the unit. When the holder
is inserted correctly, the photometer
will display Measuring followed by OPTICAL EYE
three dashes. FILLING END
d. In 10–15 seconds, the photometer FIGURE 19-24A Always hold the disposable
will display a value for the control cuvette at the square end to prevent fingerprints
cuvette. Compare this value with the or smudges from contaminating the optical eye
assigned value on the control cuvette at the filling end. (Courtesy of HemoCue,
Mission Viejo, CA)
PROCEDURE 19:5B
FIGURE 19-24B Place the tip end of the

cuvette in the middle of the drop of blood.
FIGURE 19-24C Place the filled cuvette into
the cuvette holder and gently push the holder
(Courtesy of HemoCue, Mission Viejo, CA)
into the photometer unit. (Courtesy of
eye. If air bubbles are present, discard HemoCue, Mission Viejo, CA)
the cuvette in the sharps container. into the unit. If the holder is inserted
Obtain a new cuvette and repeat the fill- correctly, Measuring followed by three
ing process with another drop of blood. dashes will appear on the display.
CAUTION: Never touch or handle the NOTE: Obtain the hemoglobin mea-
angled filling tip end of the cuvette. Fin- surement as quickly as possible after
ger marks or smudges will cause an filling the cuvette. Never wait more than
inaccurate reading. 10 minutes or test results will be inac-
NOTE: The reagent inside the cavity of curate.
the cuvette will hemolyze the erythro- 10. Within 60 seconds, the unit will display
cytes and release the hemoglobin. the hemoglobin reading in grams per
7. When sufficient blood has been deciliter (gm/dL) of blood (figure 19-
obtained, instruct the patient to hold 24D). Record the reading on the dis-
sterile gauze firmly against the puncture play.
site for at least 1–2 minutes.
minutes.
8. Use clean, lint-free tissue or lens paper
to wipe off the excess blood on the out-
side of the cuvette. Make sure you do
not draw blood out of the cuvette tip
while you are cleaning the outside sur-
face.
9. Check to make sure the photometer is FIGURE 19-24D The photometer unit
displaying Ready. Immediately place displays the hemoglobin reading in grams per
the filled cuvette into the cuvette holder deciliter (gm/dL) of blood. (Courtesy of
(figure 19-24C). Gently push the holder HemoCue, Mission Viejo, CA)
682 CHAPTER 19
PROCEDURE 19:5B
NOTE: Normal values for hemoglobin 16. Remove gloves and discard in an
are 12–18 gm/dL of blood. infectious-waste bag. Wash hands thor-
oughly
11. Record your reading as in the following
example: Hgb 12.8 gm. 17. Record the required information, on the
patient’s chart or agency form; for exam-
12. Recheck the reading to be sure it is accu-
ple, date; time; Hgb: 12.8 gm; and your
rate. Pull the cuvette holder out to the
signature and title. Report any abnor-
load position, wait until flashing dashes
mal readings immediately.
and Ready appear on the display, and
then gently push the cuvette holder
back into the unit. Within 60 seconds,
the reading will appear.
13. Remove the cuvette from the photome-
ter unit. Immediately place the used Practice
cuvette in the sharps container. Turn Go to the workbook and use the
the photometer off. evaluation sheet for 19:5B,
Measuring Hemoglobin with a
14. Check the patient to be sure the skin
Photometer, to practice this
puncture has stopped bleeding.
15. Clean and replace all equipment. Use have mastered this skill, sign the
a disinfecting solution to wipe off the sheet and give it to your instructor
outside of the photometer or follow for further action.
manufacturer’s recommendations for
cleaning. Place all contaminated dis-
posable materials in the infectious-
waste bag. Use a disinfectant to wipe Final Checkpoint Using the criteria
the counter and any contaminated listed on the evaluation sheet, your
areas. instructor will grade your performance.
19:6 INFORMATION performed, a total is kept of each type of leuko-

cyte seen by using a differential counter or calcu-
Preparing and Staining a Blood lator. The percentage of each type is then
calculated. For example, if 33 lymphocytes are
Film or Smear counted, the blood is said to contain 33 percent
A blood film or smear is used for a variety of lymphocytes. Because certain types of WBCs
blood tests. A blood smear or film is pre- increase after specific infections, the differential
pared by placing a small drop of blood on a slide. count aids in making diagnoses. For example,
Another slide, coverslip, or special spreader is after certain viral illnesses, an increase in lym-
then used to spread the blood in a thin layer phocytes (a specific type of leukocyte) is often
across the slide. noted. Likewise, an infection involving certain
An important test that uses the blood film or parasites can lead to an increase in the number of
smear is the differential count of white blood eosinophils, another type of leukocyte.
cells (WBCs). There are five different types of The blood film or smear is also used to exam-
WBCs, or leukocytes, each with its own charac- ine the form, structure, and relative number of
teristic appearance. The types of leukocytes are erythrocytes (red blood cells, or RBCs), leuko-
discussed in detail in Chapter 7:8. In a differential cytes, and platelets (figure 19-25). In addition to
count, 100 WBCs are counted. As the count is abnormal blood counts, abnormal shapes can
FIGURE 19-25 A photomicrograph of a slide

stained with Wright’s stain and showing erythrocytes
and platelets (1,000X). FIGURE 19-26 A quick stain, or three-step
method, is another way of staining blood smear
slides.
also be signs of diseases. For example, a sickle-
shaped RBC can indicate the presence of sickle
cell anemia. Abnormal shapes and an increase in
leukocytes are seen in certain types of leukemia.
All the equipment used for preparing the dipped into a fixative solution for about 1 second.
blood smear or film must be extremely clean. It is then dipped into two separate staining solu-
Fingerprints, smears, stains, and other similar tions for approximately 1 second each (figure
contaminants will interfere with, and in some 19-26). This three-step procedure is repeated four
cases even distort, the appearance of the cells. to five times following manufacturer’s instruc-
Wiping the slide and spreader with alcohol is one tions. Then the slide is gently rinsed with water
way to remove contaminants. and allowed to air-dry before it is examined. This
Before the slide can be viewed under a micro- method is faster and requires less than 1 minute
scope, the cells must be stained so that they are to complete. It is important to read and follow
visible. A common stain is Wright’s stain. The manufacturer’s instructions to obtain a properly
stain fixes the smear, or makes the cells in the stained blood smear.
blood adhere to the slide. When a buffer is then
added, the stain colors or dyes the blood cells so STUDENT: Go to the workbook and complete
that they become visible under the microscope. the assignment sheet for 19:6, Preparing and
Another common stain is a quick stain, or Staining a Blood Film or Smear. Then return and
three-step method. The blood smear slide is continue with the procedures.
684 CHAPTER 19
PROCEDURE 19:6A
Preparing a Blood Film anticoagulant, pressure should be held
or Smear against the puncture site for at least 3–5
minutes.
Equipment and Supplies CAUTION: Remain with the patient
Lancet, alcohol swab, sterile gauze, alcohol,
slide, coverslip or spreader slide, disposable 8. Place the edge of the coverslip or
gloves, mask, protective eyewear, gown, spreader slide in front of the blood on
sharps container, infectious-waste bag the slide (figure 19-27A).
9. Hold the spreader slide at a 30–45-
Procedure degree angle. Pull the spreader back
until it touches the blood. Hold it steady
1. Assemble equipment. while the blood spreads evenly to the
2. Wash hands. Put on gloves. If splashing edges of the spreader slide (figure 19-
of blood is possible, put on a gown, face 27B).
mask, and protective eyewear. 10. Using a firm, steady movement, push
CAUTION: Observe standard precau- the spreader to the opposite end of the
tions while obtaining and testing blood. slide (figure 19-27C). Use a smooth,
continuous motion. Keep the spreader
3. Use an alcohol swab to clean the slide
in contact with the slide at all times. Fin-
and coverslip (spreader slide). Check
ish by raising the spreader in a smooth,
both for defects or chips. Any defects
low arc. If the coverslip or spreader slide
could interfere with the smear pattern.
is disposable, put it in the sharps con-
4. Introduce yourself. Identify the patient. tainer. If it is not disposable, wash it
Explain the procedure. Obtain the thoroughly and clean or soak it in a dis-
patient’s consent. infecting solution.
5. Perform a skin puncture. Wipe off the 11. Allow the slide to air-dry. It is now ready
first drop of blood. Put the used lancet for staining.
in the sharps container immediately.
NOTE: The smear should be approxi-
6. Place a small drop of blood on the slide mately 11⁄2 inches long, smooth, thin,
by touching the slide to the blood. The and have an even margin on all sides.
drop of blood should be placed approxi-
NOTE: If the slide cannot be stained
mately 1⁄4 to 1⁄2 inch from the end of the
immediately, immerse the dried smear
slide and centered on the slide.
in methanol for 30–60 seconds to fix the
CAUTION: Do not touch the slide to the slide and preserve the smear. Remove
skin because doing so will cause the the slide from the methanol solution
blood to smear. and allow it to air-dry.
NOTE: The blood drop should be 12. Check the patient to be sure that the
approximately 2 millimeters in diame- skin puncture has stopped bleeding.
ter, or the size of a matchhead.
13. Clean and replace all equipment. Put all
7. When sufficient blood has been contaminated disposable supplies in
obtained, instruct the patient to hold the infectious-waste bag. Use a disin-
sterile gauze firmly against the puncture fectant to wipe the counter and any
site for at least 1–2 minutes. contaminated areas.
PROCEDURE 19:6A
A. B. C.
FIGURE 19-27 To prepare a blood smear: (A) place the edge of the spreader slide in front of the
drop of blood on the slide; (B) hold the slide at a 30–45-degree angle and pull it back until it touches
the drop of blood; (C) use a firm, steady movement to push the spreader slide to the opposite end of
the slide.

infectious-waste bag. Wash hands.
Practice
Preparing a Blood Film or Smear, to
PROCEDURE 19:6B
Staining a Blood Film Procedure
or Smear 1. Assemble equipment.
2. Wash hands. Put on gloves. If splashing
Equipment and Supplies of blood is possible, put on a gown,
Blood smear film slide, staining rack, Wright’s mask, and protective eyewear.
stain with distilled water/buffer solution or CAUTION: Observe standard precau-
quick stain kit, timer, disposable gloves, mask, tions while obtaining and testing blood.
protective eyewear, gown, infectious-waste
bag 3. Prepare a blood smear film (described
in Procedure 19:6A) if you have not
already done so.
686 CHAPTER 19
PROCEDURE 19:6B
Wright's Wright's
stain buffer
A. B.
FIGURE 19-28 (A) Use Wright’s stain to cover the dry smear. (B) After waiting 1–3 minutes, add an
equal amount of distilled water or buffer solution.
NOTE: The slide should be smooth and c. Wash the slide by flooding it gently
have an even margin on all sides. There with distilled water. Allow the stain
should be no streaks, hesitation marks, mixture to flow off of the slide.
or holes.
6. To stain the slide with a quick stain kit:
4. Place the slide with the smear side up
a. Read the manufacturer’s instruc-
on a staining rack. Make sure the rack is
tions.
level.
b. Dip the slide into the fix solution for
5. To stain the slide with Wright’s stain:
about 1 second.
a. Use Wright’s stain to completely cover
c. Quickly dip the slide into each of the
the dry smear (figure 19-28A). Count
two staining solutions for about 1
the number of drops of the stain as
second each.
you apply it. Leave the stain in place
for 1–3 minutes. NOTE: Touch the end of the slide on a
paper towel between solutions to
NOTE: The time and number of drops
remove excess solution. Do not allow
may vary with different stains; read and
the slide to dry between solutions.
follow manufacturer’s instructions.
d. Repeat the three-step dip process
b. Add an equal amount of distilled
approximately four to five times, fol-
water or buffer (figure 19-28B). Place
lowing manufacturer’s instructions.
it on the slide one drop at a time.
Between drops, blow gently along the e. Rinse the slide gently with water (if
length of the slide to mix the stain and required by the manufacturer).
water. Allow it to stand 2–4 minutes. 7. Wipe the dye from the back of the slide.
NOTE: The solutions are well mixed Observe which part of the slide has the
when an oily, greenish sheen appears. heaviest concentration of blood smear.
Stand the slide on its end (vertically) to
CAUTION: Make sure none of the mix-
dry. Place the part with the heaviest
ture runs off of the slide.
concentration downward and allow the
dye to flow down from the less concen-
PROCEDURE 19:6B
trated (thinner) area. In an emergency, fectant to wipe the counter and any
the front of the slide can be blotted dry, contaminated areas.
but this is not recommended. It is best
to allow the slide to air-dry at room tem-
perature.
8. The finished smear should have a laven-
der-pink color. If it appears too purple,
hold the slide under gently running cold
water until the desired color is obtained. Practice
Let the water strike the slide above the Go to the workbook and use the
thick portion of the smear and flow evaluation sheet for 19:6B, Staining
downward. a Blood Film or Smear, to practice
NOTE: The slide is now ready to be
examined. A differential count of leuko-
cytes is usually done with this type of the sheet and give it to your
stain. Examinations of erythrocytes and instructor for further action.
platelets can also be done.
9. Clean and replace all equipment. Put all Final Checkpoint Using the criteria
contaminated disposable supplies in listed on the evaluation sheet, your
the infectious-waste bag. Use a disin- instructor will grade your performance.
♦ Type A contains antigen A on the RBCs.

19:7 INFORMATION
♦ Type B contains antigen B on the RBCs.
Testing for Blood Types ♦ Type AB contains both antigen A and antigen
Human beings inherit a certain blood type B on the RBCs.
from their parents. The type of blood is
♦ Type O contains neither antigen A nor antigen
determined by the presence of certain factors,
B on the RBCs.
called antigens, on red blood cells (RBCs), or
erythrocytes. An antigen is a substance, usually Red blood cells are not the only body cells
a protein, that causes the body to produce a pro- with the A and B antigens. Most other cells also
tein, called an antibody, that reacts against the have them. Thus, in forensic (legal) medicine, a
antigen. An antigen may be introduced into the piece of skin or other tissue found at a crime
body, such as the antigens that enter the body as scene can be typed. In this way, the blood type of
viruses, or an antigen may be formed within the the victim and/or criminal can be determined.
body, such as the RBCs that contain antigens. The In addition to an ABO blood type, every indi-
variety of antigens that may be present on the vidual has an Rh type. Rh stands for rhesis mon-
RBCs serve as the basis for blood group systems key, in which it was first found. In the Rh blood
and blood types. Two of the major systems are type system, only one factor, the D antigen, is
called the ABO blood type system and the Rh sys- involved. If the Rh factor, or D antigen, is present
tem. on the RBCs, the blood type is called Rh positive.
In the ABO blood type system, two specific If the Rh factor is not present, the blood type is
antigens can be present: antigen A and antigen B. called Rh negative.
There are four main blood types: A, B, AB, and O. If an antigen not present in a person’s RBCs is
The letters refer to the kind of antigen present in introduced into the blood, the individual will
the RBCs of an individual. produce antibodies to destroy the foreign anti-
688 CHAPTER 19
gen. These antibodies remain in the individual’s the D antigen. When these antibodies enter the
blood plasma or serum. They are specific for a developing infant’s bloodstream through the pla-
particular antigen, or act against only the antigen centa, the antibodies can hemolyze or destroy
they were produced to act against. These anti- the infant’s red blood cells. Fortunately, a medi-
bodies destroy the RBCs having the foreign anti- cine called RhoGAM can be given to the pregnant
gen in one of two main ways. They cause the RBCs woman to prevent the information of the anti-D
to either hemolyze (dissolve and go into solution, antibodies. The RhoGAM injection is usually
releasing hemoglobin) or to agglutinate (clump given to the woman once or twice during the
together). Because RBCs carry oxygen and car- pregnancy and within 72 hours after delivery if
bon dioxide to maintain vital body functions, the infant is Rh positive.
their destruction can lead to death. The procedure that follows demonstrates
Before anyone can receive a transfusion blood typing using an anti-A serum and an anti-B
(transfer of blood from one individual to another), serum; the Rh factor is checked using an anti-Rh,
a typing and crossmatch must be performed or anti-D, serum. The three serums are designed
on the blood. The blood typing reveals the ABO, to cause an agglutination reaction if the antigens
Rh factors, and other, rarer blood type systems. are present in the blood. Thus, if the blood reacts
Crossmatching consists of a series of tests per- to the anti-A serum by agglutinating, but does
formed on the blood of the donor (the person giv- not react to the anti-B serum, only antigen A is
ing blood) and on the blood of the recipient (the present, and the blood type is type A (figure 19-
person receiving blood). The purpose is to detect 29). Conversely, if the blood reacts to the anti-B
any possible incompatibility or difference that serum but does not react to the anti-A serum,
would make the blood unsuitable for transfusion only antigen B is present, and the blood type is B.
between the recipient’s serum and the cells of the If the blood reacts to both the anti-A serum and
donor. Most blood banks also do an antibody the anti-B serum, both antigen A and antigen B
screen of blood prior to a transfusion being per- are present, and the blood type is AB. If the blood
formed. This screening is performed to check for reacts to neither the anti-A serum nor the anti-B
unexpected antibodies that may be present in the serum, neither antigen is present, and the blood
blood and that could lead to an incompatibility type is O. If the blood reacts to the anti-Rh serum,
reaction. Only when the two types of blood are the Rh factor is present, and the blood is Rh posi-
compatible, or identical in antigens and antibod- tive. If the blood does not react to the anti-RH
ies present, can the blood from one individual be serum, the Rh factor is not present, and the blood
given to another individual. type is Rh negative. This test is used only for
Blood typing is also performed on pregnant screening purposes. Additional and more exten-
women. An Rh incompatibility between a preg- sive laboratory tests are performed on blood
nant woman and the fetus (developing infant) before a transfusion is given.
can cause hemolytic disease of the newborn
(HDN). The problem occurs when the woman is
Rh negative and the fetus is Rh positive. The Rh STUDENT: Go to the workbook and complete
antigen, or D antigen, enters the mother’s blood- the assignment sheet for 19:7, Testing for Blood
stream through the placenta. The mother’s blood- Types. Then return and continue with the proce-
stream then produces anti-D antibodies against dure.
Red blood cells

A NTI-A to be tested A NTI-B
SE RUM SE RUM
ANTI-B
ANTI-A
Type O
No agglutination No agglutination
Type A
Agglutination No agglutination
Type B
No agglutination Agglutination
Type AB
Agglutination Agglutination
FIGURE 19-29 Blood typing ABO groups with antiserums.
690 CHAPTER 19
PROCEDURE 19:7
Place a third drop of blood on the sec-
Testing for Blood ond slide, labeled Rh.
Types CAUTION: Take care not to touch the
skin to the slide.
Equipment and Supplies 6. When sufficient blood has been
Alcohol swab, sterile lancet, sterile gauze, obtained, instruct the patient to hold
anti-A serum, anti-B serum, anti-D (anti-Rh) sterile gauze firmly against the puncture
serum, two clean slides, three mixing sticks, site for at least 1–2 minutes.
Rh-typing viewbox with heater, wax pencil,
disposable gloves, mask, protective eyewear,
gown, sharps container, infectious-waste bag,
paper, pen or pencil
minutes.
Procedure CAUTION: Remain with the patient

1. Assemble equipment. Check to make 7. Place one drop of anti-A serum next to
sure both slides are clean or use an alco- the first drop of blood. Immediately mix
hol swab to clean each slide. Allow the the blood and serum with a mixing stick.
slides to air-dry. Use the wax pencil to Discard the stick in the sharps con-
mark one slide into two halves. Label tainer.
one half with A and the other half with
B. Label the second slide with Rh. Turn CAUTION: Work quickly, before the
on the Rh-typing viewbox to allow it to blood clots.
heat to 37°C. Check the expiration dates 8. Place one drop of anti-B serum next to
on the antiserum bottles and make sure the second drop of blood. Mix immedi-
the solutions are at room temperature. ately with a second mixing stick. Discard
NOTE: Old antiserums will not produce the stick in the sharps container.
accurate test results. Serums should be 9. Place one drop of anti-Rh or D serum
discarded on their expiration dates. next to the third drop of blood on the
2. Wash hands. Put on gloves. If splashing second slide. Mix immediately with a
of blood is possible, put on a gown, third mixing stick. Discard the stick in
mask, and protective eyewear. the sharps container. Place this slide on
the Rh-typing viewbox. The viewbox will
CAUTION: Observe standard precau- heat the slide to 37°C and gently rock
tions while obtaining and testing blood. the slide back and forth for 2 minutes.
3. Introduce yourself. Identify the patient. NOTE: The blood must be at body tem-
Explain the procedure. Obtain the perature to obtain an accurate reaction
patient’s consent. to the anti-D or Rh serum.
4. Perform a skin puncture as previously 10. Gently rock the slide containing the
instructed. Wipe off the first drop of anti-A and anti-B serums back and forth
blood. Put the used lancet in the sharps for at least 1–2 minutes. Make sure the
container immediately. drops of blood do not mix together. This
5. Place two drops of blood on the first allows the antigens in the blood to react
slide, one drop on the half labeled A and with the serums. Using a strong light,
the second drop on the half labeled B. check for an agglutination, or clumping,
30216_19_Ch19_648-714.indd 690 1/16/08 12:42:22 PM

PROCEDURE 19:7
reaction in the two drops of blood. 15. Clean and replace all equipment. If the
Agglutination indicates a positive reac- slides are disposable, put them in the
tion. If the reaction is positive, the cells sharps container. If the slides are not
will clump together. If the reaction is disposable, wash them thoroughly and
negative, the blood will remain then clean or soak them in a disinfect-
unchanged. ing solution. Put all contaminated dis-
posable supplies in the infectious-waste
11. At the end of 2 minutes, check the Rh
bag. Use a disinfectant to wipe the coun-
slide on the viewbox. Use a strong light
ter, viewbox, and other contaminated
and observe for agglutination. If the
areas.
cells have agglutinated, the reaction is
positive, and the Rh factor is present in 16. Remove gloves and discard in an infec-
the blood. If the blood remains tious-waste bag. Wash hands.
unchanged, the reaction is negative,
and the Rh factor is not present in the
blood.
example, date, time, Blood Type AB,
12. Use the following chart to determine and your signature and title. Report any
blood type based on serum agglutina- abnormal readings immediately.
tion reactions.
TYPE OF ANTI-RH
BLOOD ANTI-A ANTI-B OR ANTI-D
O
A
Negative
Positive
Negative
Negative
Practice
B Negative Positive evaluation sheet for 19:7, Testing for
AB Positive Positive Blood Types, to practice this
Rh positive Positive
Rh negative Negative
13. Recheck any questionable results. Cor- sheet and give it to your instructor
rectly record the information. for further action.
NOTE: Blood type is noted as A positive
(A), AB negative (AB–), and so forth for
the various blood types.
14. Check the patient to make sure the skin listed on the evaluation sheet, your
puncture has stopped bleeding. instructor will grade your performance.
19:8 INFORMATION time. The test is also called a sedimentation rate,

or sed rate. Venous blood is used for this test. An
Performing an Erythrocyte anticoagulant, such as oxalate or sequestrene, is
added to the blood to prevent clotting. The blood
Sedimentation Rate is then placed in a special tube. The RBCs fall and
An erythrocyte sedimentation rate is another settle in the tube. The distance is measured in
blood test for erythrocytes or red blood cells millimeters by using graduated marks on the tube
(RBCs). An erythrocyte sedimentation rate or rack. The measurement is taken at the point
(ESR) measures the distance that RBCs fall and where the clear plasma line is noted above the
settle in a glass test tube in a specific period of settled RBCs (figure 19-30).
692 CHAPTER 19
various readings and times are then placed on a
0 10
0 10 graphic chart. By reading the chart, the physician
can determine both the rate and distance of fall
Plasma Distance for the RBCs.
1 9 erythrocytes Two main methods are used to perform an
have fallen
ESR: the Wintrobe and the Westergren. Both
2 8
methods provide the same results, but the
1 9 National Committee for Clinical Laboratory Stan-
dards recommends the Westergren system. This
3 7
system is a completely closed system and elimi-
nates the manual transfer of blood that can result
4 6 in leakage, overfilling, and spraying from the
transfer pipette. The method used will depend on
5 5
the preference of the health care facility. No mat-
ter which method is used, it is essential to read
Blood
and follow the manufacturer’s instructions to
6 4
obtain accurate results.
Normal values for ESR can vary slightly. The
7 3 normal range depends to some extent on the test
kit or method used. Most normal values for the
8 2
Wintrobe method are 0–20 millimeters per hour
(mm/hr) for adult women and 0–9 mm/hr for
adult men. Most normal values for the Wester-
9 1
gren method are 0–20 mm/hr for adult women
younger than 50 years, 0–30 mm/hr for women
50 years or older, 0–15 mm/hr for adult men
younger than 50 years, and 0–20 mm/hr for men
FIGURE 19-30 Read the level at the marked line 50 years or older.
between the cells and the plasma of the blood. The
A faster-than-normal sedimentation rate sig-
example shown is 8 millimeters (mm).
nifies that inflammation and/or cell destruction
has taken place. This may occur in conjunction
In order for the RBCs to fall and settle cor- with many medical conditions, including infec-
rectly, the tube containing the blood must be tions, cancers (such as certain carcinomas and
placed in a special rack. The rack is designed to leukemia), inflammatory processes (such as rheu-
hold the tube in an exact vertical position. Many matic fever and rheumatoid arthritis), and acute
sedimentation racks contain a level indicator. viral hepatitis. Pregnant or menstruating female
This indicator must be adjusted so that the rack is individuals may also have an increased sedimen-
100 percent level with it. The sedimentation rack tation rate. A slower-than-normal sedimentation
must also be placed on a counter that is free of rate can occur in conjunction with polycythemia
vibrations and not exposed to a heating/cooling (a high number of RBCs), sickle-cell anemia, cer-
vent or direct sunlight. The test must be contain types of heart disease (such as congestive
ducted at room temperature to obtain accurate heart failure), and severe liver disease.
results.
Measurements of ESR are usually taken at STUDENT: Go to the workbook and complete
specific time periods. Some laboratories check the assignment sheet for 19:8, Performing an
the distance at 20-minute intervals. A measure- Erythrocyte Sedimentation Rate. Then return and
ment is always taken at the 1-hour period. The continue with the procedure.
PROCEDURE 19:8
Performing an
Erythrocyte
Sedimentation Rate
Venous blood with oxalate or sequestrene
(anticoagulant), sedimentation rack, sedi-
mentation-rate tubes, transfer pipette, timer,
disposable gloves, mask, protective eyewear,
gown, infectious-waste bag, paper, pen or
pencil
FIGURE 19-31 If a level indicator is present, turn
Procedure the platform knobs to center the bubble in the
indicator and to level the sedimentation rack.
1. Assemble equipment. Read the manu-
5. To perform an ESR by the Wintrobe
facturer’s instructions carefully.
method:
2. Wash hands. Put on gloves. If splashing
a. Place the sedimentation tube in the
of blood is possible, put on a gown,
rack. Make sure the black line on the
mask, and protective eyewear.
tube is at the zero on the rack.
NOTE: The tube must be clean and dry
for an accurate measurement.
3. Check the sedimentation rack. Make
NOTE: The tube can also be filled with
sure the rack is level. Check the bubble
the proper amount of blood first and
or level indicator for the level mark if
then placed in the rack.
one is present. Make sure the rack is on
a counter that is free of vibrations and b. With a transfer pipette, withdraw
not exposed to direct sunlight or a heat- blood from the blood tube into the
ing/cooling vent. pipette and place the filled pipette in
the bottom of the sedimentation-rate
NOTE: If the rack has a level indicator,
tube (figure 19-32). Gradually with-
turn the platform knobs located near
draw the pipette while expelling the
the feet to center the bubble in the indi-
blood to prevent air bubble forma-
cator and level the rack (figure 19-31).
tion. Fill the tube to the zero mark.
4. Obtain venipuncture blood that has
NOTE: Before placing the pipette in the
been mixed with an anticoagulant.
sedimentation-rate tube, use a gentle,
Blood should be at room temperature.
even motion to expel all air from the
Make sure the stopper is secure on the
bottom of the pipette.
test tube containing the blood. Invert
the tube and shake it gently for 3–5 min- NOTE: If air bubbles are present, start
utes to thoroughly mix the blood. over.
NOTE: Health occupation students are 6. To perform an ESR using the Sediplast
not permitted to obtain blood by veni- Westergren method:
puncture unless they receive special
a. Remove the stopper on the diluting
training.
vial. Fill the vial with the venipunc-
694 CHAPTER 19
PROCEDURE 19:8
FIGURE 19-33 For the Westergren Sediplast

method, gently push the disposable pipette
down into the diluting vial. The pipette will fill
automatically. Note the empty diluting vials with
stoppers on the right. (Courtesy of POLY-
FIGURE 19-32 For the Wintrobe method, MEDCO, Inc.)
transfer the blood from the pipette to the
sedimentation-rate tube, taking care to keep the zero mark. Excess diluted blood will
pipette below the level of the blood at all times flow into the sealed reservoir com-
to prevent air bubble formation. partment.
7. Recheck the level of the rack.
ture blood to the line indicated on
8. The RBCs will fall and settle. At the
the vial.
time(s) specified, read the level to which
NOTE: The diluting vials contain a 3.8- the RBCs have fallen. Most tests are
percent sodium citrate solution that done at 20-, 40- and 60-minute inter-
dilutes the blood sample. vals. Most laboratories record only a 60-
minute reading.
b. Replace the stopper and gently invert
the vial three to six times to mix the NOTE: Read at eye level. Take the read-
blood and dilutent. ing at the marked line between the cells
and plasma of the blood (refer to figure
c. Place the vial in the Sediplast rack.
19-30).
d. Use a gentle twisting motion to push
9. Record the readings in millimeters
a disposable pipette through the
(mm). Note the time of each reading.
pierceable stopper on the vial. Push
Make sure all readings are recorded.
down until the pipette touches the
bottom of the vial (figure 19-33). The NOTE: Normal readings vary. Check the
pipette will fill automatically to the manufacturer’s instructions to deter-
PROCEDURE 19:8
mine normal values for the test kit
used.
10. Clean and replace all equipment. Most
tubes are disposable. Place disposable
Practice
tubes in a sharps container. Put other evaluation sheet for 19:8,
contaminated disposable supplies in Performing an Erythrocyte
the infectious-waste bag. Use a disin- Sedimentation Rate, to practice this
fectant to wipe the rack, counter, and
any other contaminated areas.
11. Remove gloves and discard in an infec- sheet and give it to your instructor
tious-waste bag. Wash hands thor- for further action.
oughly.
example, date; time; ESR Westergren: 12
mm/hr; and your signature and title. Final Checkpoint Using the criteria
Report any abnormal readings immedi- listed on the evaluation sheet, your
ately. instructor will grade your performance.
19:9 INFORMATION proper diet can maintain normal blood-sugar

level. However, the dosage of insulin required can
Measuring Blood-Sugar vary depending on body metabolism, food intake,
amount of exercise, other illness, and stress. For
(Glucose) Level this reason, many diabetics are taught to check
Many health care careers involve measuring blood-sugar levels and regulate insulin dosages
blood-sugar (glucose) level. Glucose is a based on glucose levels. Because too much insu-
form of sugar found in the bloodstream. Insulin, lin can lead to severe hypoglycemia, or low
which is produced by the islets of Langerhans in blood sugar, and a condition called insulin shock,
the pancreas, normally allows glucose to cross proper insulin dosage is essential.
cell membranes so that it can be metabolized. In A variety of blood tests can be used to check
a disease known as diabetes mellitus, however, the level of glucose. One method of checking
there is an insufficient amount of insulin. Indi- blood-sugar level is a fasting blood sugar
viduals with diabetes, therefore, cannot metabo- (FBS). This test is usually performed in medical
lize glucose, or convert it into energy. Glucose laboratories. The patient does not eat or drink
builds up in the bloodstream. Excess amounts anything (fasts) for 8–12 hours before the test. A
are filtered out by the kidneys and eliminated venipuncture is done to obtain a sample of blood,
from the body in the urine. Hyperglycemia, or and the amount of glucose is checked. Normal
high blood sugar, and glycosuria, or sugar in fasting blood sugar is 70–110 milligrams per deci-
the urine, are two main signs of diabetes. liter (mg/dL) of blood.
Individuals with diabetes control their dis- Another test called the glucose tolerance
ease by following calculated diets that meet nutri- test (GTT) evaluates how well a person metabo-
tional needs while controlling blood-sugar levels. lizes a calculated amount of glucose. The GTT is
In some cases, diet control can regulate blood- frequently used to diagnose diabetes. The patient
sugar level. However, many individuals with dia- fasts for 8–12 hours before the GTT. Blood and
betes must also take insulin injections to control urine specimens are obtained and tested for fast-
blood-sugar levels. Correct insulin dosage and ing levels. The patient then drinks a calibrated
696 CHAPTER 19
amount of glucose. Blood and urine specimens icals on the pad, color changes occur. The amount
are usually obtained and tested at 30 minutes, 1 of glucose present can be determined by com-
hour, 2 hours, and 3 hours, but test times vary. paring the color on the chemical-reagent pad to a
Normally, the glucose ingested would be metab- color chart usually located on the bottle of reagent
olized by the end of the GTT, and blood and urine strips. This method is not as accurate because it
levels of glucose would be in normal ranges. In a relies on the operator performing a color match.
person with diabetes mellitus, the levels would Usually the strips are placed in a special photom-
remain elevated. eter or glucose meter. The glucose meter provides
Another blood test that is performed on indi- a more accurate reading of the reagent strip and
viduals with diabetes is the glycohemoglobin shows the amount of glucose in milligrams by
test (HbA1C or HbA1). This test measures the way of numbers that light up on the screen.
amount of glucose that attaches to the hemoglo- The following steps should be taken to obtain
bin on red blood cells (RBCs). Because RBCs live the most accurate results,
approximately 120 days or 4 months, this test
provides information on the average blood-sugar ♦ Store all reagent strips properly. Reagent strips
levels for the previous 2–3 months. Although nor- are very sensitive to heat, light, and moisture.
mal values depend on the test used, a common They should be stored in a dark, dry, cool area,
normal range is 4.0–6.0 percent. A person with but should not be refrigerated. The bottle con-
well-controlled diabetes averages 6–7 percent. A taining the strips is usually made of dark or
person with untreated or uncontrolled diabetes light-resistant glass. To prevent contamina-
might have levels of 10–12 percent or even higher. tion from moisture in the air, close the bottle
If the glycohemoglobin level rises, it indicates immediately after use.
that the patient’s diabetic management plan ♦ Handle the reagent strips carefully. Never
must be improved. This can be accomplished by touch the chemical-reagent pad(s).
more frequent evaluations of daily glucose levels, Chemicals and moisture on the skin can
changes in the type or dosage of insulin, and/or cause inaccurate results. In addition, the
stricter dietary control. The American Diabetes chemicals on the strips can burn or injure the
Association recommends that individuals with skin.
diabetes with good glucose control be tested for ♦ Read all instructions carefully. Times and pro-
glycohemoglobin levels once or twice a year. Dia- cedure methods vary with different strips. A
betics with poor control should have the test four few require rinsing before a reading is taken.
times a year. Others must be blotted at a set time interval. If
In past years, most individuals with diabetes a glucose meter is used, it is important to use
checked the level of glucose in the urine. A high the strip designed for that particular brand of
level of glucose in the urine can indicate a high meter.
blood-sugar level, because excess glucose is fil-
tered out of the blood by the kidneys. However, ♦ Read all instructions provided with the glu-
urine tests do not always accurately indicate a cose meter. To ensure accuracy, meters have
current blood-sugar level because the urine may to be calibrated before use. Test strips or solu-
show glucose that was excreted several hours ear- tions are used to calibrate the meter. Different
lier. Therefore, individuals with diabetes are now time intervals and procedures are used for dif-
encouraged to check blood-glucose levels rather ferent meters.
than urine-glucose levels. Advantages of checking ♦ Some new glucose meters do not require the
blood glucose include increased accuracy com- use of reagent strips. An example is the
pared to urine tests, unlimited flexibility with HemoCue glucose meter (figure 19-34). A dis-
regard to timing of the test, ability to detect both posable cuvette is filled with a drop of blood
low and high glucose levels, better regulation of and the cuvette is inserted into the holder on
insulin dosage, and improved control of diabetes. the side of the unit. When the cuvette holder is
It is now possible to use reagent strips to test pushed into the unit, the photometer mea-
blood-sugar level. These are plastic strips sures the glucose level in 15–240 seconds and
with a chemical-reagent pad or pads. A drop of displays the reading on the monitor. The
blood from a skin puncture is placed on the pad. cuvette is then discarded in a sharps con-
When glucose in the blood reacts with the chem- tainer. It is important to measure the sample
of blood within 40 seconds to obtain the most

accurate results.
♦ Glucose meters must be cleaned carefully after
each use. Accumulation of dirt, dust, or other
residue can lead to inaccurate readings. Most
manufacturers recommend specific cleaning
procedures. Lens paper is frequently recom-
mended to prevent scratching the screen.
Water is usually the only solution used for
cleaning because alcohol can damage many
meters. If possible, disinfect the meter.
Most patients check their own blood-
glucose levels. Even children can be taught
to monitor their own blood-sugar levels. Patients
must be given complete instructions on the cor-
rect procedure to use. Correct skin puncture
techniques must be taught. Asepsis must be
stressed. Proper use and storage of reagent strips
and operation and cleaning of the glucose meter
must be demonstrated. Patients frequently are
taught to determine insulin dosages based on
glucose levels, so their determinations of glucose
levels must be as accurate as possible.
FIGURE 19-34 A disposable cuvette is filled with STUDENT: Go to the workbook and complete
blood and inserted into the HemoCue glucose the assignment sheet for 19:9, Measuring Blood-
meter. The glucose level is displayed on the screen Sugar (Glucose) Level. Then return and continue
in 15–240 seconds. Reagent strips are not used with the procedure.
with this type of glucose meter. (Courtesy of
HemoCue, Mission Viejo, CA)
PROCEDURE 19:9
and/or glucose meter used. Follow specific
Measuring Blood- manufacturer’s instructions.
Sugar (Glucose) Level
Procedure
1. Assemble equipment. Carefully read
Sterile lancet, alcohol swabs, sterile gauze, instructions provided with the glucose
glucose reagent strips or disposable cuvette reagent strips and the glucose meter.
(depending on which glucose meter is used), Make sure the reagent strips are com-
glucose meter, lens paper, tissues or blotter patible with the meter. Note times that
paper, watch or timer with second hand, dis- must be observed during each step of
posable gloves, mask, protective eyewear, the procedure.
gown, sharps container, infectious-waste bag,
paper, and pen or pencil 2. Wash hands. Put on gloves. If splashing
of blood is possible, put on a gown,
NOTE: The method used varies slightly mask, and protective eyewear.
depending on the type of reagent strip
698 CHAPTER 19
PROCEDURE 19:9
CAUTION: Observe standard precau- side of the glucose meter (refer to figure
tions while obtaining and testing blood. 19-34). Gently push the cuvette holder
into the glucose meter. Within 15–240
3. Calibrate the glucose meter for accu-
seconds, the glucose reading will be dis-
racy. Follow the manufacturer’s instruc-
played on the screen. Steps 10 and 11 of
tions. Most meters have test reagent
this procedure are not used with this
strips or solutions that are placed on a
type of glucose meter.
reagent strip to check calibration.
NOTE: In some glucose meters, the
reagent strip is inserted into the meter
first. Then the end of the strip is placed
in the drop of blood. The strip uses cap-
NOTE: It is best to seat the patient in a illary action to draw the blood into the
comfortable position. meter where the glucose is measured
5. Perform the procedure for a skin punc- and the value displayed.
ture. Place the used lancet in the sharps 9. When sufficient blood has been
container immediately. obtained, instruct the patient to hold
6. Use sterile gauze to remove the first sterile gauze firmly against the skin
drop of blood. puncture for at least 1–2 minutes.
7. Remove one reagent strip from the CAUTION: If the patient is taking an
bottle, being careful not to touch the anticoagulant, pressure should be held
chemical-reagent pad on the strip. against the puncture site for at least 3–5
Immediately close the lid of the bottle. minutes.
CAUTION: If the chemical reagent pad CAUTION: Remain with the patient
touches the skin, injury or burns can until the bleeding stops.
occur, as can inaccurate readings. 10. The glucose meter signals with a beep
8. Press the start button on the glucose or light when the blood has been on the
meter. A beep or light usually indicates strip for the required period of time. If
the correct time for placing a large drop necessary, blot the strip gently by plac-
of blood on the reagent strip. Make sure ing it between a fold of tissue or blotter
the drop of blood completely covers the paper. Some glucose meters do not
chemical-reagent pad. Hold the strip require blotting of the reagent strip, so it
level to avoid spilling the blood. Do not is important to follow manufacturer’s
allow the chemical-reagent pad to touch instructions.
the skin while applying the drop of NOTE: Blood usually remains on the
blood. strip for 10–60 seconds. It is important
NOTE: If the glucose meter uses a dis- to follow the time period established by
posable cuvette instead of a reagent the manufacturer because this is a cru-
strip, place the tip end of the cuvette cial step.
into the middle of the drop of blood. CAUTION: Never wipe the strip while
Hold the cuvette steady to allow the blotting it. Wiping removes too much
chamber to fill completely through cap- of the blood and causes inaccurate
illary action. Use a lint-free tissue or lens results.
paper to wipe off excess blood on the
11. Immediately insert the strip into the
outside of the cuvette. Immediately
correct position in the meter (figure
place the cuvette into the holder on the
PROCEDURE 19:9
19-35). Most manufacturers require that container. Use a disinfectant to wipe the
the reagent pad face the window on the counter and any contaminated areas.
meter. Check to be sure the strip is in Follow the manufacturer’s instructions
the correct position. Follow manufac- for proper cleaning of the glucose
turer’s instructions to obtain an accu- meter.
rate reading.
NOTE: Most manufacturers recommend
12. Record your reading in milligrams (mg), using lens paper and water to clean the
for example, 102 mg. Be sure to include window, strip slot, and other areas on
the date, time, glucose test, your name the meter. A disinfectant solution should
or initials, and other required informa- then be put on these areas unless pro-
tion. Double-check your reading for hibited by the manufacturer.
accuracy.
15. Remove gloves and discard in an infec-
13. Check the patient to make sure that tious-waste bag. Wash hands thor-
bleeding from the skin puncture has oughly.
stopped.
14. Clean and replace all equipment. Place patient’s chart or the agency form; for
the reagent strip and any contaminated example, date; time; Blood Glucose: 102
disposable equipment in the infectious- mg; and your signature and title. Report
waste bag. If a disposable cuvette was any abnormal readings immediately.
used, place the cuvette in the sharps
Practice
evaluation sheet for 19:9, Measuring
Blood-Sugar (Glucose) Level, to
FIGURE 19-35 Insert the reagent strip into Final Checkpoint Using the criteria
the correct position in the glucose meter to listed on the evaluation sheet, your
obtain an accurate blood-glucose level. instructor will grade your performance.
regarding urine, specifically normal and abnor-

19:10 INFORMATION mal characteristics of urine. Refer to this table as
you perform the basic urine tests.
Testing Urine A urinalysis is an examination of urine and
Urine tests are often done to determine the consists of three main areas of testing: physical,
physical condition of a patient. Abnormal chemical, and microscopic.
urine tests are often the first indications of a dis- Physical testing of urine is usually done first
ease process. Table 19-1 provides the main facts and consists of observing and recording color,
700 CHAPTER 19
TABLE 19-1 Characteristics of Urine

CHARACTERISTIC NORMAL ABNORMAL
Volume or amount 1,000—2,000 mL daily Polyuria—increased amount, more than 2,000 mL in 24 hours
Oliguria—decreased amount, less than 500 mL in 24 hours
Anuria—no formation
Color Some shade of yellow; Pale or colorless—dilute
straw-yellow to amber Dark yellow, orange, or brown—concentrated
Yellow or beer-brown—bilirubin or bile pigment, can precede jaundice
and indicate hepatitis
Cloudy-red—caused by presence of red blood cells (RBCs) (hematuria)
Clear-red—hemoglobin, due to increased RBC destruction
Transparency Clear Cloudy because of pus, mucus, white blood cells (WBCs), and/or old
specimen
Milky because of fats or lipids
Odor Faintly aromatic Ammonia—old specimen
Foul/putrid—bacteria or infection
Fruity or sweet—acetone or ketones, diabetes mellitus
pH reaction Range 5.5–8.0, average 6 Alkaline—infection, chronic renal failure, or old specimen
(mildly acidic) High acidity—diarrhea, starvation, and ketones (diabetes mellitus)
Specific gravity 1.005–1.030 Increased—diabetes mellitus, concentrated urine, low fluid intake,
dehydration
Decreased—renal disease, diluted urine, high fluid intake, diuretic
medications (water pills)
Glucose None Presence, glycosuria, may mean diabetes mellitus
Albumin, protein None to trace Presence, proteinuria or albuminuria, can indicate kidney disease
Acetones–ketones None Presence, ketonuria, can indicate starvation, diabetes mellitus, or a
high-fat diet
Blood None Presence, hematuria, indicates kidney, ureter, or bladder disease or
infection
Pus None Presence, pyuria indicates infection in urinary system
Bacteria None in catheter Large amount may indicate infection
specimen
Small amount in routine
specimen is normal
Red blood cells None to less than 2–3/hpf Presence may indicate disease of kidneys, bleeding in the urinary tract
(Erythrocytes) (high-power field)
White blood cells Few normal; less than Large number indicates infection
(Leukocytes) 4–5/hpf
Bilirubin None Presence, bilirubinuria, can indicate liver disease, hepatitis, or bile-
duct obstruction
Urobilinogen 0.1–1.0 EU/dL Presence can indicate liver disease, destruction of red blood cells
(Ehrlich units per (RBCs) (hemolytic diseases)
deciliter)
odor, transparency, and specific gravity. The urine collecting urine are discussed in detail in Chapter
specimen should be fresh and mixed gently prior 21:10.
to being checked for physical characteristics. The For the most accurate results, a urinalysis
normal and abnormal physical characteristics should be performed on fresh, warm urine. If
are listed in Table 19-1. possible, a urine specimen should be examined
Chemical testing of urine is performed to within 1 hour after it is collected. If this is not
check pH, protein, glucose, ketone, bilirubin, possible, the specimen can be refrigerated. After
urobilinogen, and blood. Reagent strips, de- refrigeration, it should be returned to room tem-
scribed in detail in Information section 19:11, are perature before being examined.
usually used for chemical testing. Diseases indi- Urine is a body fluid, so standard precau-
cated by the presence of abnormal chemicals in tions (Chapter 14:4) must be observed while
the urine are listed in Table 19-1. collecting and handling urine. Hands must be
Microscopic testing of the urine is done to washed frequently, and gloves must be worn at all
examine formed elements in the urine, such as times. If splashing of the urine is possible, a mask,
cells, casts, crystals, and amorphous deposits. To protective eyewear, and protective clothing must
do a microscopic examination, the urine is cen- be worn. Urine should be discarded in a toilet but
trifuged to spin out the solid particles and form is sometimes poured down a sink. If this is done,
urinary sediment. This procedure is described in the sink must be flushed with water and wiped
detail in Information section 19:13. The sediment with a disinfectant. Any areas contaminated by
is then examined under a microscope and the urine must be wiped with a disinfectant. The
checked for the presence of blood cells, bacteria, specimen containers and other contaminated
casts (formed in the kidney tubules and expelled disposable supplies must be discarded in the
during kidney damage), and other elements. infectious-waste bag prior to being discarded as
A variety of specimen containers is available infectious waste according to legal require-
for collecting urine. Most containers are clear, ments.
calibrated in milliliters (mL), and disposable. The
container should have a secure lid to prevent STUDENT: Go to the workbook and complete
spillage (figure 19-36). Most routine urine speci- the assignment sheet for 19:10, Testing Urine.
mens can be collected in a nonsterile container.
Sterile containers are required if the urine is being
cultured or tested for the presence of organisms
such as bacteria. All specimen containers must
19:11 INFORMATION
be labeled with the patient’s name, date, time of Using Reagent Strips
collection, and test ordered. Some facilities also
require a patient identification number and the
to Test Urine
doctor’s name on the label. Different methods of This section describes the urine reagent
strip (dipstick) test, which is frequently used
as a screening test for urine. Many different types
of reagent strips are available, and all work
according to the same basic principles. Read the
label of the reagent strip container for direc-
tions.
Excess amounts of many substances in the
blood are eliminated from the body by the kid-
neys as part of urine. By testing the urine for the
presence of these substances, certain diseases in
the body can be detected. The most common
method of testing for the presence or absence of
these substances is the use of the urine reagent
strip, or dipstick.
Urine reagent strips are firm, plastic strips.
FIGURE 19-36 Urine specimen containers should Small pads containing chemical reactants are
have a secure lid to prevent spillage. attached to the strip. Each pad reacts to a specific
702 CHAPTER 19
substance. If the substance is present in the urine, ♦ Glucose is usually metabolized to produce
it reacts with the chemical reactant on the strip energy and is not normally found in the urine.
and produces a color change. In addition to show- If the level of glucose in the blood is high, glu-
ing the presence of the substance, most of the cose will be eliminated in the urine, a condi-
chemical reactants will also measure the amount tion called glycosuria. The presence of glucose
of the substance present by producing different can indicate diabetes mellitus.
color changes according to the amount of sub-
stance present.
♦ Ketones and acetones are the end products of
the metabolism of fat in the body. They are not
Most urine reagent strips are sensitive to
normally found in the urine. Their presence
light, heat, and moisture. They must be
(ketonuria) can indicate diabetes mellitus,
stored in a dry, cool, dark area. The bottle con-
starvation, fasting, dieting, a high-fat diet, and
taining the strips is usually made of dark or light-
metabolic disorders.
resistant glass. A moisture-absorbent pad or pack
is usually present in the bottle. The bottle must ♦ Blood is not normally found in the urine. A test
be closed immediately after use. Care must be sometimes shows positive for blood when the
taken not to touch or handle any of the chemical- patient is menstruating. If blood is detected in
reactant pads on the strip. Chemicals and mois- the urine, a microscopic examination of the
ture on the skin can lead to an inaccurate test. In urine should be performed. Blood in the urine
addition, many of the chemicals on the strip are is called hematuria. Its presence can indi-
poisonous and can burn or injure the skin. Many cate injury, infection, or disease in the kidneys
patients use reagent strips in their homes for spe- and/or urinary tract.
cific urine tests, so it is important to make sure ♦ Bilirubin is not usually present in the urine. It
that the patient understands the importance of is a breakdown product of the hemoglobin on
correct storage and handling of reagent strips. red blood cells (RBCs) and is usually elimi-
The patient should be cautioned against storing nated through the intestines. Its presence (bil-
the strips in a bathroom, on windowsills, or close irubinuria) in the urine can indicate liver
to sources of heat. The strips must also be stored disease such as hepatitis or bile duct obstruc-
out of the reach of children. tion.
Chemical reactants on the pads of the strips
are effective only for a certain period of time. An ♦ Urobilinogen is bilirubin that has been con-
expiration date is printed on every bottle of strips. verted by intestinal bacteria. It is usually
Reagent strips should never be used after the excreted by the intestines. Small amounts of
expiration date because inaccurate test results 0.1–1.0 Ehrlich units (EU) per deciliter of urine
will occur. In an agency where many bottles of are normal. The presence of larger amounts
strips are kept in stock, it is important to rotate usually indicates heart, spleen, liver, or hemo-
the strips so that the bottle with the closest expi- lytic (destruction of blood cells) disease.
ration date is used first. ♦ Phenylalanine is an amino acid (protein) that
Reagent strips can be used to test for a variety is excreted in the urine when it is not metabo-
of substances present in the urine. Some of the lized by the body. Its presence indicates phe-
more common ones include the following: nylketonuria (PKU), a congenital disease that
causes mental retardation if not detected early.
♦ pH is a measure of the acidity or alkalinity of For this reason, most states require a PKU
urine. pH is measured on a scale of 1–14. A neu- blood and/or urine test for all newborns.
tral pH is 7. A pH below 7 indicates acidic urine,
and a pH above 7 indicates alkaline urine. Urine Many different types of reagent strips are
is usually slightly acidic, with a pH range of available. Some of the more common types and
5.5–8.0. Diet, medications, kidney disease, star- the substances they test for include:
vation, and diabetes can each change pH. ♦ Albustix: protein
♦ Protein should be retained in the blood and it ♦ Bili-Labstix: pH, protein, glucose, ketone, bili-
is not normally found in the urine. Its pres- rubin, and blood
ence (proteinuria), usually in the form of albu-
min (albuminuria), may indicate kidney ♦ Chemstrip-GK: glucose and ketone
disease. ♦ Chemstrip-GP: glucose and protein
♦ Clinistix: glucose
♦ Combistix: pH, glucose, and protein
♦ Diastix: glucose
♦ Hemastix: blood
♦ Keto-Diastix: glucose and ketone
♦ Ketostix: ketone
♦ Labstix: pH, glucose, protein, ketone, and
blood
♦ Multistix: pH, specific gravity, glucose, pro-
tein, ketone, blood, bilirubin, urobilinogen,
and nitrite
♦ Phenistix: phenylalanine
♦ Uristix: protein, glucose, nitrites, and leuko-
cytes
It is important to read the instructions care-
fully when using any type of reagent strip. A color
comparison chart is usually located on the bottle FIGURE 19-37 The Chemstrip Mini UA urine
of reagent strips or on a paper enclosed in the analyzer is one example of an automated strip
box. This chart lists the substances to be tested reader that analyzes the reagent strip more accu-
and the correct time interval for reading each rately than the human eye. (Courtesy of Boehringer
reaction. The exact time for reading each chemi- Mannheim)
cal reaction must be followed for the most accu-
rate results. Adequate lighting is essential to
correctly match colors.
Most laboratories and offices perform erated specimens should be allowed to return to
quality-control checks on reagent strips to make room temperature prior to being tested. Results
sure the strips produce accurate results. A urine are most accurate if testing can be done immedi-
control solution, with predetermined results, is ately after collecting the specimen, while the
tested with a reagent strip. If the results do not specimen is still warm.
meet the predetermined range, the strips must When results of the test are recorded, the
type of test used must be specified, for
not be used. Quality-control checks should be
example, Labstix or Multistix. All substances
run at least once a day, whenever a new container
tested must be listed along with the results for
of strips is opened, and any time test results seem
each. The date and time of the test should also be
questionable.
noted. Put your name or initials near the record-
Automated strip readers or analyzers are
ing. A sample charting is as follows:
available (figure 19-37). The strip readers, or
spectophotometers, analyze the color change 1/30/–9:00 A.M. Miss Smith
and intensity for each reagent on the strip. The Labstix Test: pH: 6
results are displayed on a lighted screen and/or Protein: neg.
printed. The automated strip readers are more Glucose: 1%
accurate than the human eye, but they are expen- Ketone: mod.
sive. Blood: neg.
Fresh urine specimens should be used to
obtain the greatest degree of accuracy with a STUDENT: Go to the workbook and complete
reagent strip. Urine should be tested within 1 the assignment sheet for 19:11, Using Reagent
hour of collection. If this is not possible, the urine Strips to Test Urine. Then return and continue
specimen should be refrigerated. However, refrig- with the procedure.
704 CHAPTER 19
PROCEDURE 19:11
Using Reagent Strips
to Test Urine
Fresh, early-morning urine specimen, if pos-
sible; urine-specimen container; reagent
strips and color comparison chart; dispos-
able gloves; infectious-waste bag; paper; pen
or pencil; watch with second hand or timer
Procedure
FIGURE 19-38A Hold the reagent strip by
1. Assemble equipment. Read instructions
the clear end to immerse the strip in the urine
for the reagent strip. specimen.
tions while obtaining and testing urine.
4. Obtain a fresh urine specimen in a
urine-specimen container.
NOTE: An early-morning, first-voided
specimen is the most concentrated and
therefore is preferred.
5. Gently rotate the container between FIGURE 19-38B Tap the edge of the strip
your hands to mix the urine specimen. lightly on a paper towel or against the side of
the specimen container to remove excess urine.
6. Hold a reagent strip by the clear end
(figure 19-38A). Immerse the strip in the tally near the color comparison charts
urine specimen, making sure all reagent on the bottle (figure 19-38C).
areas are submersed.
9. Note the time. A watch or clock with a
7. Remove the strip immediately. Tap the second hand is essential because many
edge of the strip lightly on a paper towel readings are done in a period of sec-
or against the side of the specimen con- onds.
tainer to remove excess urine (figure 19-
38B). 10. Start at the center of the strip. Read any
reagent areas that require immediate
NOTE: This will prevent urine from readings. Record these readings.
dropping on the color comparison chart
during color matching. 11. Watch the time and read additional
reagent areas at the correct time inter-
8. Turn the strip so that the reagent areas vals. Some are read at 10 seconds, 15
are facing you. Hold the strip horizon- seconds, 30 seconds, or 60 seconds.
Record all readings.
PROCEDURE 19:11
tious-waste bag. Wash hands.
patient’s chart or the agency form; for
example: date, time; Labstix: pH: 6, Pro-
tein: neg., Glucose: 1%, Ketones: Tr.,
Blood: Neg; and your signature and title.
Report any abnormal readings to your
supervisor immediately.
FIGURE 19-38C Under good lighting,

compare the strip to the color charts to deter-
mine correct readings.
NOTE: The time lapses between read-
ings are usually sufficient to allow you
Practice
to read readily down the strip. evaluation sheet for 19:11, Using
12. Recheck all readings. Using a second Reagent Strips to Test Urine, to
reagent strip to check accuracy of results practice this procedure. When you
is sometimes required. believe you have mastered this skill,
13. Discard the strip and any contaminated sign the sheet and give it to your
disposable supplies in the infectious- instructor for further action.
waste bag. Pour the urine into a toilet or
down a sink. If a sink is used, flush the
sink with water and wipe with a disin-
fectant. Use a disinfectant to wipe the Final Checkpoint Using the criteria
counter and any contaminated areas. listed on the evaluation sheet, your
Clean and replace all equipment. instructor will grade your performance.
19:12 INFORMATION ♦ Low specific gravity, below 1.005, is usually

caused by diluted urine possibly resulting
Measuring Specific Gravity from excessive fluid intake, kidney disease in
which the kidneys cannot concentrate urine,
Specific gravity is defined as the weight of
diuretic medications, or diabetes insipidus.
a substance compared to the weight of dis-
tilled water, in equal volumes. Specific gravity of ♦ High specific gravity, above 1.030, is usually
urine, then, is the weight of urine compared to caused by concentrated urine possibly result-
the weight of an equal amount of distilled water. ing from low fluid intake, dehydration, exces-
The weight of distilled water is 1.000. Its specific sive fluid loss through other body parts, kidney
gravity is expressed as: Sp. Gr. 1.000. Specific grav- disease in which too many substances are
ity of urine, therefore, is a measurement of the excreted, and/or diabetes mellitus, in which
concentration of urine. sugar is present in the urine.
The normal range for specific gravity of urine
is 1.005–1.030 with most specimens ranging One way to determine specific gravity is to
between 1.010 and 1.025. Variations occur as fol- measure it with a urinometer. Urine is
lows: poured into a urinometer jar or cylinder. The uri-
706 CHAPTER 19
nometer, which is a float with a calibrated stem,

is placed in the urine with a spinning motion. The 320
310
urine collects at a line at a curved angle on the 15
300
290
urinometer float. This line is known as the menis- 14
280
270
cus. The reading for specific gravity is taken at the 13
260
250
lower part of the meniscus. It must be read at eye 12
240
230
level to be accurate. Each calibration on the uri- 11
220
210
nometer float is in thousandths. The top line rep- SERUM OR PLASMA
10
200
PROTEIN 190
resents 1.000, the specific gravity of distilled GMS/100 ml 9
180
T/C 170
water, and each small line below it represents PR/N RATIO 6.54
8
160
150
0.001. The calibrations read 1.000, 1.001, 1.002, 7
140
130 REFRACTION
1.003, 1.004, and so forth. It is important that the 1.035
6
120 (N-No) 104
110
T/C
urinometer be free floating and away from the 1.030
5
100
90
sides and bottom of the jar or cylinder when the URINE
1.025 4
80
70
reading for specific gravity is taken. SPECIFIC GRAVITY
T/C
1.020 3
60
1.015 50
Another way to determine specific gravity is 1.010
40
30
with a refractometer (figure 19-39A). One drop 1.005 20
10
of well-mixed urine is placed on the refractome- 1.000 0
ter. Specific gravity is read by looking through an

ocular, or eyepiece. The degree of concentration FIGURE 19-39B The urine forms a line on the
of the urine forms a line on the refractometer refractometer scale. This specimen shows a specific
scale (figure 19-39B). It is important to follow gravity of 1.034.
manufacturer’s instructions and to calibrate the
refractometer with distilled water when it is
used.
Digital refractometers are also available. An
eye dropper is used to place drops of urine on the
prism at the center of the stainless-steel stage
(figure 19-40). The refractometer then reads the
specific gravity and displays the value on the
screen. This eliminates the chance of human
error in reading the scale.
All refractometers must be tested for accu-
racy before use. Most manufacturers provide test
strips or test solutions that show a preset reading.
FIGURE 19-40 A digital refractometer automati-
cally reads specific gravity when drops of urine are
placed on the prism at the center of the stainless-
steel stage.
Distilled water can also be used to check the

refractometer because it should show a specific
gravity of 1.000. The manufacturer’s instructions
will also provide information on how to calibrate
the refractometer if the test reading is not accu-
rate.

the assignment sheet for 19:12, Measuring Specific
FIGURE 19-39A A refractometer can be used to Gravity. Then return and continue with the proce-
calculate specific gravity of urine. dure.
PROCEDURE 19:12
6. To check specific gravity using a uri-
Measuring Specific nometer, proceed as follows:
Gravity a. Fill the urinometer jar or cylinder with
urine to within 1 inch from the top.
Equipment and Supplies NOTE: Make sure the urine is mixed
Urine specimen in a container, urinometer well.
float, urinometer jar or cylinder, refractome-
b. Using paper or a piece of gauze,
ter, transfer pipette or eye dropper, dispos-
remove any bubbles from the top of
able gloves, infectious-waste bag, paper
the urine.
towels or gauze, paper, pencil or pen
c. Grasp the urinometer stem at the top
Procedure and slowly insert it into the jar or cyl-
inder containing the urine. Avoid
1. Assemble equipment. wetting the top of the stem. As you
insert the urinometer float, twirl it
2. To use a urinometer, clean the urinom- slightly so that it does not stick to the
eter float and cylinder or jar thoroughly sides.
and make sure they are dry. To use a
refractometer, place one drop of dis- NOTE: A spinning float will not stick
tilled water on the glass plate and close to the sides of the urinometer jar or
the lid gently. Look through the eyepiece cylinder.
and read the specific gravity to make d. Make sure the float is away from the
sure it is 1.000. If it is not, the refractom- sides of the jar and that it is not
eter must be calibrated according to touching the bottom of the jar or cyl-
manufacturer’s instructions. Use lens inder. The urinometer must be free
paper to dry and clean the glass plate. floating.
NOTE: Dirty equipment will interfere e. When the urinometer float stops
with the reading. spinning, take the reading at eye level
3. Wash hands. Put on gloves. at the lower line of the meniscus (fig-
ure 19-41).
tions while obtaining and testing urine. NOTE: Do not read above the meniscus.
This is inaccurate. Normal specific grav-
4. Introduce yourself. Identify the patient. ity is 1.005–1.030.
patient’s consent. CHECKPOINT: Your instructor will
check the accuracy of your reading.
5. Obtain a fresh urine specimen. Do not
refrigerate the specimen because this 7. To check specific gravity using a refrac-
can alter the test results. It is best to per- tometer, proceed as follows:
form the test as soon as possible after a. Use a transfer pipette or eye dropper
obtaining the urine. The most accurate to place one drop of well-mixed urine
results are obtained when the urine is at on the glass plate of the refractome-
room temperature. ter (figure 19-42A).
NOTE: An early-morning, first-voided b. Close the lid gently.
specimen is the most concentrated and
is therefore preferred. c. Look through the eyepiece and read
the specific gravity on the scale (fig-
ure 19-42B).
708 CHAPTER 19
PROCEDURE 19:12
FIGURE 19-41 To check specific gravity with

a urinometer, read the specific gravity of urine
at eye level at the lower line of the meniscus.
FIGURE 19-42B Look through the eyepiece to
read the specific gravity on the refractometer scale.
oughly, rinse or soak with a disinfectant,

and dry both pieces completely. To clean
the refractometer, follow manufacturer’s
instructions. Most manufacturers rec-
ommend using lens paper on the glass
to prevent scratches. A disinfectant can
be put on the lens paper to clean the
glass, and another sheet of lens paper
FIGURE 19-42A Place one drop of well- can be used to dry the glass. Put all con-
mixed urine on the glass plate of the taminated disposable supplies in the
refractometer. infectious-waste bag. Use a disinfectant
to wipe the counter and any contami-
nated areas.
check the accuracy of your reading.
8. Record the reading.
9. Recheck the reading, if necessary. oughly.
10. Clean and replace all equipment. To 12. Record all required information on the
clean the urinometer and jar or cylinder, patient’s chart or the agency form; for
pour the urine into a toilet or sink. If a example, date; time; SpGr: 1.011; and
sink is used, flush the sink with water your signature and title. Report any
and wipe with a disinfectant. Wash the abnormal readings to your supervisor
urinometer and jar or cylinder thor- immediately.
PROCEDURE 19:12
Practice
Measuring Specific Gravity, to
19:13 INFORMATION Some health care facilities add a dye stain to

the urine to color various elements and make it
Preparing Urine for Microscopic easier to identify them. Usually one to two drops
of a urine stain is added to the sediment before
Examination placing the sample on the slide.
Microscopic testing of urine is done to The size of the drop of concentrated urine
examine all the solid materials suspended examined is important. The drop of sediment
in the urine. These materials are called urinary placed on a slide for viewing will be covered with
sediment. Presence of certain substances, such a coverslip. The drop should be large enough so
as blood cells, casts, and bacteria, can indicate that there is no empty space under the coverslip
disease conditions of the kidneys, urinary tract, but not so large as to cause the coverslip to float.
and/or blood. The urinary sediment should be examined
A fresh, early-morning, first-voided specimen immediately after it is placed on the slide. Drying
is preferred. This type of specimen is usually the of the specimen occurs quickly, and this can
most concentrated; thus, it is more likely to con- result in distortions in the shapes and sizes of any
tain abnormal substances. The specimen should substances present.
be examined immediately, if at all possible. Cer- Learning to identify various substances
tain elements, such as red cells and casts, disinte- detected during a microscopic examination of
grate rapidly in warm specimens. If the urine the urine requires training and experience. Some
cannot be examined immediately, it should be of the substances that may be seen in urinary
kept cold to preserve these substances. sediment are shown in figure 19-43. Elements
Only a portion of the urine specimen is actu- such as epithelial cells and certain casts can be
ally examined under a microscope. The entire seen with the low-power objective. Other ele-
specimen is first mixed well. A small amount, ments, such as blood cells, bacteria, and crystals,
usually 10–15 milliliters (mL), is then placed in a can be seen only with the high-power objective.
centrifuge tube. This tube is then put into a cen- When recording the elements seen, it is impor-
trifuge. The centrifuge spins the urine, causing tant to note the objective used. This is usually
any solid materials to settle to the bottom of the recorded as per low-power field (lpf) or per high-
tube. These solid materials are called sediment. power field (hpf). For example, a recording might
The clear urine on the top of the tube is poured state, epithelial cells: mod/lpf.
off, leaving approximately 1 milliliter (mL) of sed- Microscopic examination of urinary sedi-
iment in the bottom of the tube. This procedure ment is not a CLIA waived test. It is classi-
results in concentrated urine, which is then fied as a moderately complex test. Only legally
examined under a microscope. qualified individuals can perform the actual
710 CHAPTER 19
FIGURE 19-43 Some elements that may be found in urinary sediment.
examination of the sediment. However, centri- examines the sediment and identifies the ele-
fuging the specimen and preparing the slide is ments present. Follow your agency’s policy
within the realm of duties for laboratory or medi- regarding this procedure.
cal assistants in most states. It is the responsibility
of the health care provider to know and follow STUDENT: Go to the workbook and complete
state regulations. In many settings, the laboratory the assignment sheet for 19:13, Preparing Urine
assistant prepares the urine for microscopic for Microscopic Examination. Then return and
examination and a specially trained individual continue with the procedure.
PROCEDURE 19:13
6. Pour 10–15 milliliters (mL) of urine into
Preparing Urine for a small measuring cup.
Microscopic 7. Pour the measured urine into a clean
Examination centrifuge tube.
NOTE: Residue or dirt in the tube can
Equipment and Supplies cause inaccurate results.
Urine specimen in a container, centrifuge, 8. Place the centrifuge tube in the centri-
small measuring cup, centrifuge tube, micro- fuge (figure 19-44A). Make sure there is
scopic slide, coverslip, transfer pipette, uri- another tube containing an equal
nary-sediment chart, disposable gloves, amount of urine or water opposite this
infectious-waste bag, paper, pen or pencil centrifuge tube; the second tube acts to
counterbalance the weight of the first.
Procedure 9. Centrifuge the urine for 4–5 minutes at
approximately 1,500 revolutions per
1. Assemble equipment. minute.
2. Wash hands. Put on gloves. 10. Carefully pour off 9–14 mL of the clear
CAUTION: Observe standard precau- urine. Leave 1 mL of urine and the sedi-
tions while obtaining and testing urine. ment in the bottom of the tube.
3. Introduce yourself. Identify the patient. 11. Gently shake the tube to resuspend the
Explain the procedure. Obtain the sediment in the bottom of the remain-
patient’s consent. ing 1 mL of urine.
4. Obtain a fresh, early-morning, first- NOTE: If a urine stain is used to color
voided specimen. This type of specimen the elements, add one to two drops of
is preferred because it is the most con- the stain to the sediment. Gently shake
centrated and yields the most accurate the tube to mix the sediment and stain.
results. 12. Using care, transfer one drop of the well-
5. Mix the urine well to suspend any sedi- mixed sediment to a clean glass slide
ment that has settled to the bottom. (figure 19-44B).
FIGURE 19-44A After pouring 10–15 millili-

ters (mL) of urine into the centrifuge tube, place FIGURE 19-44B Transfer one drop of well-
the tube in the centrifuge. mixed sediment to a clear glass slide.
712 CHAPTER 19
PROCEDURE 19:13
NOTE: The size of the drop is important. Note which substances are best
If it is too large, it will cause the cover- viewed under high power according
slip to float. If it is too small, it will not to the chart.
fill the area under the coverslip.
16. When the slide has been examined by a
13. Hold the coverslip at an angle to the legally qualified individual, clean and
drop of urine. Carefully drop the slip replace all equipment. Pour the urine
into place. Make sure that no air bubbles into a toilet or down a sink. If a sink is
are present. used, flush the sink with water and wipe
with a disinfectant. Place all contami-
NOTE: Air bubbles will interfere with
nated disposable supplies in the infec-
the examination. If any air bubbles are
tious-waste bag. Use a disinfectant to
present, discard the drop on the slide
wipe the counter and any contaminated
and use another drop of the urine.
areas. Cover the microscope.
14. Place the slide on the microscope stage.
Hold it in place with slide clips.
CAUTION: Hold the slide level at all oughly.
times to prevent the urine from running
18. Check that all required information has
off the slide.
been recorded on the patient’s chart or
15. Inform the physician or laboratory tech- the agency form; for example, date;
nologist that the slide is ready to be time; Microscopic Exam: epithelial:
examined. Examination of the sediment few/lpf, WBCs: 4–6/hpf, RBCs: few/hpf,
is not a CLIA waived test. The following casts: neg, crystals: few/hpf; and signa-
steps for examining the sediment are ture and title.
included only for practice examination.
a. Use the low-power (10X) objective
and the coarse adjustment to bring
the slide into focus.
CAUTION: Watch the stage while using
the coarse adjustment to move the
objective down toward the slide. Practice
b. Adjust the lighting to allow the best
viewing of the slide. A dimmer light
Preparing Urine for Microscopic
usually provides a clearer view under
Examination, to practice this
low power.
c. Use a chart on urinary sediment or have mastered this skill, sign the
refer to figure 19-43 to identify some sheet and give it to your instructor
of the substances present in the uri- for further action.
nary sediment.
NOTE: The examination should be com-
pleted within 3 minutes. Drying occurs
after this time and can lead to inaccu-
rate identification.
d. Switch to the high-power objective listed on the evaluation sheet, your
and examine the specimen again. instructor will grade your performance.

Blood tests that can find cancer before a tumor even develops?
Cancer kills. This is a well-known fact. Another fact is that if cancer is detected and
treated early, the chance of survival is much greater. Researchers all over the world are con-
stantly looking for diagnostic tests that will allow physicians to find cancer in its earliest
stages, even before the tumors can be seen on radiographs.
A cancer cell is not something that enters the body. It is a body cell that has changed its
normal functions and growth patterns to become an abnormal cell. These abnormal cells
are detected by the body’s immune system because they contain substances called antigens.
The immune system recognizes these antigens as foreign substances and tries to destroy
them. Researchers have discovered that these antigens can be detected in the blood. They
call the antigens “tumor markers.” A large number of markers that indicate the presence of
specific types of cancer have been identified. A common example is the prostate-specific
antigen (PSA). This antigen is present in the blood when a man has cancer of the prostate
gland.
Blood tests have been developed to find the tumor markers. However, the tests currently
are expensive and are not always 100-percent accurate. Currently, most physicians use these
blood tests to ensure that the amount of markers has decreased or disappeared after treat-
ment for a specific type of cancer. However, researchers are working to find more specialized
blood tests that will identify the presence of tumor markers accurately at minimal expense.
When this occurs, a simple blood test will diagnose cancer in many different parts of the
body at an early stage. Hopefully, this will lead to early treatment and increase cancer sur-
vival rates.
CHAPTER 19 SUMMARY blood typing, hemoglobin, hematocrit, eryth-

rocyte sedimentation rate, blood smear or film,
Laboratory assistant skills are utilized not only in and blood glucose. Following proper techniques
medical laboratories, but also in medical offices and striving for accuracy are essential because
and nursing care facilities. A basic knowledge of these tests are used to determine the presence or
the major types of tests performed is beneficial absence of disease.
for many different health care workers. Urine tests are performed to check the func-
Because the microscope is used in many lab- tion of various body organs. The presence of ab-
oratory tests, the health care worker should be normal substances in the urine is frequently the
familiar with how to operate it. first indication of disease. A urinalysis, or exami-
Obtaining culture specimens and preparing nation of the urine, usually involves three areas
them for examination helps the health care proof testing: physical, chemical, and microscopic.
fessional determine the cause of a disease and, The health care worker should be familiar with
often, the proper way to treat the disease. Many each of these areas and be able to perform the
of the specimens contain communicable patho- tests with precision and accuracy.
gens (germs capable of spreading disease), so Standard precautions must be followed at all
care must be taken while performing these pro- times while performing laboratory tests. Many
cedures. diseases are transmitted by blood and body flu-
Blood tests are performed for a variety of rea- ids, so extreme care must be taken while han-
sons. Some of the more common tests include dling these substances.
714 CHAPTER 19
INTERNET SEARCHES REVIEW QUESTIONS

1. What is the purpose of a culture and sensitivity
study? Differentiate between sensitive and
resistant organisms.
1. Organizations: locate Web sites for the Ameri-
2. List six (6) points that must be checked prior to
can Medical Technologists Association, Ameri-
performing a skin puncture to obtain blood.
can Society for Clinical Laboratory Science,
National Accrediting Agency for Clinical 3. Differentiate among an erythrocyte count,
Laboratory Sciences, American Red Cross hematocrit, and hemoglobin.
(blood donations), and the American Diabetic 4. State the normal values or ranges for each of
Association (blood glucose testing) to research the following tests:
basic laboratory tests a. microhematocrit
2. Science: research microbiology, bacteria, b. hemoglobin
viruses, and microorganisms c. erythrocyte count
d. leukocyte count
3. Blood tests: research erythrocyte, leukocyte,
e. erythrocyte sedimentation rate
hemoglobin, hematocrit, blood typing, eryth-
f. specific gravity of urine
rocyte sedimentation rate, and blood glucose
tests 5. Why is it important to evaluate the Rh status of
a pregnant woman?
4. Urine tests: research urinary reagent strips,
urinary sediments, urinalysis, and specific 6. List five (5) precautions that must be observed
gravity of urine while storing and/or using urinary reagent
strips.
5. Medical supplies: search for suppliers of
medical laboratory equipment such as hema- 7. Briefly list the components or tests performed
tocrit centrifuges, hemoglobinometers, pho- during a physical, chemical, and microscopic
tometers, glucose meters, refractometers, examination of the urine.
automated reagent strip readers, and urinom- 8. List all of the standard precautions that must
eters to compare and contrast the various be observed while performing culture studies,
products available on the market blood tests, or urine tests.
6. Laws: research the Clinical Laboratory For additional information about laboratory
Improvement Amendment (CLIA) to deter- careers, contact the following associations:
mine legal responsibilities and quality-control
standards for a medical laboratory ♦ American Medical Technologists’ Association
710 Higgins Road
Park Ridge, Illinois 60068
Internet Address: www.amtl.com
♦ American Society for Clinical Laboratory
Science
6701 Democracy Boulevard
Bethesda, MD 20814
Internet Address: www.ascls.org
♦ National Accrediting Agency for Clinical
Laboratory Sciences
8410 West Brynmawr Avenue, Suite 670
Chicago, IL 60631–3415
Internet Address: www.naacls.org
♦ State Society for Medical Technology
♦ State Society for Medical Technologists
CHAPTER 20 Medical Assistant
Skills
Chapter Objectives
Observe Standard ◆ Measure and record height and weight
Precautions ◆ Position and properly drape a patient in
horizontal recumbent, prone, Sims’, knee–
chest, Fowler’s, lithotomy, dorsal recumbent,
Instructor at This Point Trendelenburg, and jackknife positions
◆ Use a Snellen chart to screen for vision
problems
Safety—Proceed with ◆ Prepare for and assist with an eye, ear, nose,
Caution and throat examination
◆ Prepare for and assist with a gynecological
examination
on Federal Law ◆ Prepare for and assist with a general physical
examination
◆ Set up a minor surgery tray without
Math Skill contaminating equipment or supplies
◆ Set up a suture removal tray without
contaminating equipment or supplies
◆ Record and mount an electrocardiogram
◆ Use the Physician’s Desk Reference (PDR) to
Science Skill find basic information about various drugs
◆ Identify methods of administering medications
and safety rules that must be observed
Career Information ◆ Interpret Roman numerals
◆ Convert metric measurements
◆ Convert household (English) measurements
Technology
716 CHAPTER 20
KEY TERMS
auscultation (oss-kull-tay- lithotomy (lith-ought-eh- Sims’
shun) me) Snellen charts
Ayer blade (a-ur) A as in medication speculum (speck-you-lum)
“say” myopia (my-oh-pee-ah) sphygmomanometer
bandage scissors needle holder splinter forceps
cervical spatula observation stethoscope
dorsal recumbent ophthalmoscope (op-thayl- supine (sue-pine)
electrocardiogram (ECG) (ee- mow-skope) surgical scissors
leck-trow-car-dee-oh- otoscope (oh-toe-skope) sutures
gram) palpation suture removal sets
Fowler’s Papanicolaou (pah-pan-ee- tissue forceps
hemostats (hee-mow-stats) cow-low) tongue blade/depressor
horizontal recumbent percussion tonometer (tow-nom-et-er)
hyperopia (high-puh-row- percussion (reflex) hammer towel clamps
pee-ah) Physicians’ Desk Reference Trendelenburg (Tren-dell-
jackknife (protologic) (PDR) en-burg)
knee–chest prone tuning fork
laryngeal mirror (lar-ren- retractors visual acuity
gee-ul) scalpels (skal-pelz)
leads sigmoidoscope (sig-moy-
left lateral doh-skope)
CAREER HIGHLIGHTS
Medical assistants work under the supervision of physicians, and they are important mem-
bers of the health care team. Educational requirements vary from state to state but can
include on-the-job training (less frequent), 1- or 2-year health occupations education pro-
grams, and/or an associate’s degree. Certification can be obtained from the American Asso-
ciation of Medical Assistants (AAMA), and registered credentials can be obtained from the
American Medical Technologists (AMT) Association, each of which has specific require-
ments. The duties of medical assistants vary depending on the size and type of practice, and
on the legal requirements of the state in which they work. Duties are often classified as
administrative or clinical. Administrative, or “front office,” duties may include tasks such as
answering telephones, greeting patients, scheduling appointments, maintaining records,
handling correspondence, and bookkeeping. Clinical, or “back office,” duties may include
taking medical histories, recording vital signs, preparing patients for and assisting with
examinations and treatments, and performing basic laboratory tests. Some medical assis-
tants perform both administrative and clinical duties; others specialize in either adminis-
trative or clinical work. The procedures discussed in this chapter represent clinical duties. In
addition to the knowledge and skills presented in this chapter, medical assistants must also
learn and master skills such as:
Medical Assistant Skills 717
CAREER HIGHLIGHTS
◆ Presenting a professional ◆ Learning medical ◆ Utilizing computer skills
appearance and attitude terminology ◆ Performing administrative
◆ Obtaining knowledge ◆ Observing all safety duties such as answering
regarding health care precautions the telephone, scheduling
delivery systems, ◆ Practicing all principles of
appointments, preparing
organizational structure, infection control correspondence,
and teamwork completing insurance
◆ Taking and recording vital forms, maintaining
signs accounts, recording
responsibilities
◆ Performing waived medical histories, and
◆ Communicating maintaining patient
laboratory tests
effectively records
◆ Administering first aid
◆ Being sensitive to and ◆ Ordering and maintaining
and cardiopulmonary
respecting cultural resuscitation supplies and materials
diversity
◆ Promoting good nutrition
◆ Comprehending human
and a healthy lifestyle to
anatomy, physiology, and maintain health
pathophysiology
20:1 INFORMATION any changes that may indicate problems with

growth and development. The measurements are
Measuring/Recording Height usually recorded on a National Center for Health
Statistics (NCHS) growth graph (figure 20-1). The
and Weight graphed information allows the physician to
Height and weight measurements are taken check the child’s growth and compare it to the
in many health care fields. Height and average percentiles of other children the same
weight measurements are used to determine age. Abnormal growth patterns may indicate
whether a patient is overweight or underweight. nutritional deficiencies or genetic diseases.
Either of these conditions can indicate disease. The head circumference in infants can be an
Height–weight charts are used as averages. A 10- early indication of abnormal development of the
percent deviation is usually considered normal. brain. Any head circumference that measures
Height–weight measurements must be accurate. above the 95th percentile usually indicates hydro-
Always recheck your calculations. cephalus, an accumulation of fluid around the
Height–weight measurements are usually brain. This leads to increased intracranial pres-
done routinely when a patient is admitted to a sure and brain damage. Hydrocephalus can be
hospital, long-term care facility, or other health caused by abnormal development of the ventri-
care agency. They are also a part of the general cles in the brain, bacterial meningitis, and/or
physical examination in a physician’s office. In tumors. A below-normal value for head circum-
addition, the measurements provide necessary ference can be an indication of microencephaly,
information in performing and evaluating cer- or a small brain. This too can lead to mental retar-
tain laboratory tests and in calculating dosages of dation. Microencephaly can be caused by a con-
certain medications. genital defect, infections during pregnancy, a
The height, weight, and head circumference premature closure of the fontanels in the brain,
measurements of infants and toddlers is moni- drug or alcohol abuse during pregnancy (fetal
tored frequently because growth is rapid. Usually alcohol syndrome), and genetic defects. Chest
infants are checked every two months to detect circumference is also measured in infants, espe-
718 CHAPTER 20
FIGURE 20-1 The National Center for Health Statistics (NCHS) growth graph is used to monitor the growth
and development of infants and toddlers.
cially if suspicion exists of overdevelopment or A wide variety of scales are used to obtain
underdevelopment of the heart and/or lungs or a height and weight measurements. Most clinical
calcification of the rib cartilage. From birth to 1 scales contain a balance beam for measuring
year of age the head circumference is usually weight and a measuring rod for determining
greater than the chest circumference. At about height (figure 20-2A–C). Infant scales provide an
1–2 years, the head and chest circumferences are
equal. After that, the chest circumference is larger
than the head circumference. Chest circumfer-
ences may also be measured in adults with
chronic obstructive pulmonary diseases (COPDs)
such as emphysema to determine the progres-
sion of the disease.
Frequent weight measurements to monitor
excessive weight loss or gain are also done for
adults with hormone disorders such as diabetes,
thyroid disease, digestive disorders, and hyper-
tension (high blood pressure) with fluid reten-
tion. Patients with cancer or patients receiving
chemotherapy are weighed frequently to monitor
weight loss. Daily weights are often ordered for
patients with edema (swelling) due to heart, kid-
ney, or other diseases. When taking daily weights,
note the following points:
♦ Use the same scale each day.

♦ Make sure the scale is balanced before weigh-
ing the patient.
♦ Weigh the patient at the same time each day.
♦ If possible, weigh the patient early in the
morning before any food or liquids have been
consumed.
♦ Make sure the patient is wearing the same
amount of clothing each day.
♦ Ask the patient to void to empty the bladder.
Height measurements are performed more FIGURE 20-2A A sample beam-balance scale.
frequently in older adults to check for osteoporo-
sis, a degeneration of the spinal column caused
by a deterioration of cartilage and bone. As the
intervertebral disks between the vertebrae dete-
riorate, the individual will become shorter.
Careful consideration must be given to the
safety of the patient while weight and height
are being measured. Observe the patient closely
at all times. Prevent falls from the scale and pos-
sible injury from the protruding height lever.
Most patients are very weight conscious.
Parents may worry about the weight of their
children. Therefore, it is very important for the
health care worker to make only positive state- FIGURE 20-2B The weight bars. The bottom
ments while weighing a patient. In addition, pri- weights are in 50-pound increments and the top
vacy must be provided while weighing a patient. weights are in 1⁄4-pound increments.
720 CHAPTER 20
FIGURE 20-2C The height bar. The height is read

at the break point on the movable bar.
area for placing the infant in a lying-down, or flat, FIGURE 20-4 A mechanical lift with a scale is
position. Institutions, such as hospitals or long- used for patients who cannot stand or sit in a chair.
term care facilities, may have special scales for have 0.1-kilogram increments. At times, it may be
patients who are unable to stand. Such scales necessary to convert kilograms (kg) to pounds
include the wheel-chair scale (figure 20-3) and (lb) or pounds to kilograms. To convert kilograms
the bed scale with a mechanical lift (figure 20-4). to pounds, use the following formula:
Some hospitals and/or long-term care facilities Kilograms (kg) 2.2 pounds (lb)
have beds with a built-in scale that can be used to
Example: Convert 60 kilograms to pounds
weigh comatose or paralyzed patients. It is impor-
60 kg 2.2 132 lb
tant to follow the manufacturer’s instructions
while using any special scale to obtain accurate To convert pounds to kilograms, use the fol-
weight measurements. lowing formula:
Weight is recorded as pounds and ounces or Pounds (lb) 2.2 kilograms (kg)
as kilograms (1.0 kilogram 2.2 pounds). Example: Convert 110 pounds to kilograms
Most scales measure pounds in 1⁄4-pound incre- 110 lb 2.2 50 kg
ments. Metric scales measure in kilograms and
Height is recorded as feet and inches or as
centimeters. The measuring bar measures inches
and fractions or 1⁄4-inch increments. A metric
measuring bar has 1-centimeter increments. One
inch equals 2.5 centimeters. At times, it may be
necessary to convert centimeters (cm) to inches
(in) or inches to centimeters. To convert centime-
ters to inches, use the following formula:
Centimeters (cm) 2.5 inches (in)
Example: Convert 95 centimeters to inches
95 cm 2.5 38 in
To convert inches to centimeters, use the fol-
lowing formula:
Inches (in) 2.5 centimeters (cm)
Example: Convert 24 inches to centimeters
24 in 2.5 60 cm

FIGURE 20-3 A wheelchair scale is a convenient the assignment sheet for 20:1, Measuring/Record-
scale for weighing a patient who may have difficulty ing Height and Weight. Then return and continue
standing on a beam-balance scale. with the procedures.
PROCEDURE 20:1A
Measuring/Recording
Height and Weight
Balance scale, paper towel, paper, pencil or
pen
Procedure
2. Wash hands.
3. Prepare the scale. Place a paper towel
on the foot stand of the scale. Move both
weights to the zero position. If the end
of the balance bar swings freely, the
scale is balanced. If the scale is not bal-
anced, follow manufacturer’s instruc-
tions to balance the scale.
NOTE: Most scales have a small screw
by the end of the balance bar. By adjust-
ing the screw, the scale can be bal-
anced. FIGURE 20-5 The patient should stand
unassisted on the scale, with her feet centered
NOTE: The paper towel prevents spread on the platform and slightly apart.
of disease.
on the lower guide. Then move this
4. Introduce yourself. Identify the patient. weight back one notch. Move the smaller
Explain the procedure. Remember to 1
⁄4-pound weight until the balance bar
make only positive statements. swings freely halfway between the upper
5. Ask the patient to remove shoes, jackets, and lower guides. Add the two weights
heavy outer clothing, purses, and heavy together to determine the patient’s cor-
objects that may be in the pockets of rect weight. Recheck your reading.
clothing. Record the weight correctly.
NOTE: In a hospital or long-term care CHECKPOINT: Your instructor will
facility, the patient is usually weighed in check your reading for accuracy.
a gown or in pajamas. 8. Help the patient get off the scale. Raise
6. Assist the patient onto the scale. The the height bar higher than the height of
patient should stand unassisted, with the patient. Help the patient get back on
his or her feet centered on the platform the scale with his or her back to the
and slightly apart (figure 20-5). scale.
CAUTION: Watch closely at all times to CAUTION: Watch closely at all times to
prevent falls. prevent falls.
7. Move the large 50-pound weight to the 9. Instruct the patient to stand as erect as
right until the balance bar drops down possible (figure 20-6). Ask the patient to
722 CHAPTER 20
PROCEDURE 20:1A
NOTE: If the height bar is extended
above the break point of the movable
bar, remember to read the height at the
point of the break by reading in a down-
ward direction on the upper bar.
check your reading for accuracy.
12. Elevate the height bar.
13. Help the patient get off the scale.
CAUTION: Watch the patient closely to
prevent fails.
14. Replace all equipment. Throw the paper
towel in a waste can.
15. Return both weight beams to the zero
positions. Lower the measurement bar.
16. Convert the inches to feet and inches by
dividing by 12. For example 641⁄2 inches
divided by 12 equals 5 feet, 41⁄2 inches.
17. Wash hands.
FIGURE 20-6 The patient should stand as patient’s chart; for example, date; time;
erect as possible while height is being mea- Wt: 1321⁄2 lb; Ht: 5 ft, 41⁄2 in; and your sig-
sured. nature and title.
look straight ahead to keep the head

level.
10. Move the bar of the measuring scale
down until it just touches the top of the Practice
patient’s head. Go to the workbook and use the
CAUTION: Move slowly. Do not hit the
Measuring/Recording Height and
patient with the bar.
Weight, to practice this procedure.
11. Read the measurement in inches or cen- When you believe you have
timeters. Recheck your reading. Record mastered this skill, sign the sheet
the height correctly. and give it to your instructor for
NOTE: If the height is difficult to read, further action.
assist the patient off the scale without
moving the height bar. Then read the
correct height measurement.
NOTE: If the reading is in inches, it can Final Checkpoint Using the criteria
be converted to feet and inches after the listed on the evaluation sheet, your
patient is off the scale. instructor will grade your performance.
PROCEDURE 20:1B
Measuring/Recording
Height and Weight
of an Infant
Infant scale, towel or scale paper, tape mea-
sure, growth graph, patient’s chart or paper,
pencil or pen
Procedure FIGURE 20-7 While keeping one hand

slightly above the infant, adjust the scale
1. Assemble equipment. weights with the other hand.
2. Wash hands.
7. Move the large weight to the right until
3. Prepare the scale. Place a towel or scale
the balance bar drops down on the lower
paper on the scale to protect the infant
guide. Then move this weight back one
from the shock of the cold metal and
notch. Move the smaller weight until the
pathogens (germs). Then balance the
balance bar swings freely halfway
scale. Move both weights to the zero
between the upper and lower guides.
position. If the end of the balance bar
Add the two weights together to deter-
swings freely, the scale is balanced. If
mine the infant’s correct weight.
the scale is not balanced, follow manu-
facturer’s instructions to balance the NOTE: If the infant scale contains only
scale. one bar and one weight, move the weight
to the right until the balance bar swings
NOTE: Most scales have a small screw
freely halfway between the upper and
by the end of the balance bar. By adjust-
lower guide. Read the weight on the
ing the screw, the scale can be bal-
bar.
anced.
NOTE: Many offices have scales with
4. Introduce yourself. Explain the proce-
digital readouts. The weight is measured
dure to the parent. Identify the infant by
automatically when the infant is placed
asking the parent for the infant’s name.
on the scale. However, it is important to
Ask the parent to undress the infant.
make sure that you are not touching the
NOTE: An undershirt or pajama is some- infant when you read and record the
times left on the infant. weight.
5. Pick up the infant. Use one arm to sup- 8. Record the weight in pounds and ounces
port the neck and shoulders and the or in kilograms. Recheck your reading.
other arm to support the back and hips.
6. Place the infant on the scale. check your reading for accuracy.
CAUTION: Watch closely at all times. To 9. Pick up and place the infant on a flat
prevent falls, keep one hand over the surface.
infant while adjusting the scales (figure
CAUTION: Watch closely at all times. Do
20-7).
not leave the infant unattended. If it is
necessary to reach for anything nearby,
724 CHAPTER 20
PROCEDURE 20:1B
use one hand to hold the infant and the c. Use your other hand to bring the tape
other hand to reach. around the infant’s head, just above
the ears, over the occipital bone at
10. Place the zero mark of the measuring
the back of the head, and back to the
tape or rod at the infant’s head (figure
forehead to meet the zero mark on
20-8). If the measuring bar is a part of
the tape (figure 20-9).
the examination table, position the
infant so that the infant’s head is at the d. Pull the tape snug to compress the
zero mark. Ask the parent or an assistant hair, but not too tight.
to hold the head at this mark. Gently
e. Read the tape measure to the nearest
straighten the infant’s legs. If a measur- 1
⁄2 inch or 0.1 centimeter.
ing tape is used, measure to the infant’s
heel. If a bar is used, position the heel f. Record the reading.
on the bar while holding the leg 13. To measure chest circumference of the
straight. infant:
NOTE: If the infant is lying on examin- a. Lay the infant flat on his or her back.
ing table paper, mark the paper at the
infant’s head and heel. Then measure b. Use the thumb of one hand to hold
the marked area. the zero mark of the tape at the mid-
dle of the sternum.
11. Record the height correctly in inches or
centimeters. Recheck your reading. c. Use your other hand to wrap the tape
snugly under the axillary area and
CHECKPOINT: Your instructor will around the back to meet at the mid-
check your reading for accuracy. sternal area (figure 20-10).
12. The head circumference is frequently
measured on an infant. To measure head
circumference:
a. Position the infant on the examina-
tion table or ask the parent to hold
the infant.
b. Use a thumb or finger to hold the
zero mark of the tape measure against
the infant’s forehead just above the
eyebrows.
FIGURE 20-9 To measure head circumfer-

FIGURE 20-8 Hold the tape measure in a ence, bring the tape around the infant’s head,
straight line to measure an infant’s height. just above the ears, and back to the forehead.
PROCEDURE 20:1B
15. Clean and replace all equipment. Use a
disinfectant to wipe the scale. Set the
weights at zero. Fold up the tape mea-
sure.
16. Wash hands.
infant’s chart; for example, date; time;
Wt: 9 lb 8 oz; Ht: 231⁄2 in, Head circum-
ference: 163⁄4 in; and your signature and
title. The measurements should also be
recorded on the infant’s growth graph.
FIGURE 20-10 To measure chest circumfer-

ence, wrap the tape snugly around the chest
and back at the nipple line. Practice
Measuring/Recording Height and
d. Make sure the tape is at the nipple Weight of an Infant, to practice this
level of the chest and that it is not procedure. When you believe you
twisted. have mastered this skill, sign the
e. Read the measurement after the sheet and give it to your instructor
infant has exhaled or during the rest- for further action.
ing phase between respirations.
f. Read the tape measure to the nearest
1
⁄2 inch or 0.1 centimeter.
14. Return the infant to the parent. instructor will grade your performance.
During any procedure or examination,

20:2 INFORMATION reassure the patient. Make sure the
patient understands what is being done and
Positioning a Patient grants permission for the procedure. At all times,
A wide variety of positions is used for different watch the patient closely for signs of distress.
procedures and examinations. The patient may Observe all safety factors to prevent falls and
need to be positioned on a medical examination injuries. Use correct body mechanics at all times
table or a surgical table. It is important to know to prevent injury to yourself.
how to operate the table before attempting to It is also essential to make sure that the patient
position a patient. Obtain instruction or read is not exposed during any examination or proce-
manufacturer’s directions carefully. After use, dure. The door to the room should be closed, and
medical examination tables and surgical tables the curtains, if present, should be drawn. Care
are usually cleaned with an antiseptic soap and/ must be taken to properly drape or cover the
or a disinfectant solution. In addition, table paper patient to avoid unnecessary exposure. At the
is frequently used to cover an examination table same time, the drape must be applied so that the
prior to the examination and is removed and doctor or technician has ready access to the area
replaced after the examination. to be examined or treated.
726 CHAPTER 20
Some of the most common examination posi- ♦ One sheet or drape is placed over the patient
tions are listed and described. but left loose on all sides to facilitate examina-
Horizontal Recumbent (Supine) Position tion or treatment.
♦ This position is used for examination or treat- Sims’ (left lateral) Position
ment of the front, or anterior, part of the body
(figure 20-11). ♦ This position is used for simple rectal and sig-
moidoscopic examinations, enemas, rectal
♦ The patient lies flat on the back with the legs temperatures, and rectal treatments (figure
slightly apart. 20-13).
♦ One small pillow is allowed under the head. ♦ The patient lies on the left side.
♦ The arms are flat at the side of the body. ♦ The left arm is extended behind the back.
♦ The drape is placed over the patient but left ♦ The head is turned to the side. A small pillow
loose on all sides to facilitate examination or may be used.
treatment.
♦ The right arm is in front of the patient, and the
Prone Position elbow is bent.
♦ This position is used for examination or treat- ♦ The left leg is bent, or flexed, slightly.
ment of the back or spine (figure 20-12). ♦ The right leg is bent sharply at the knee and
♦ The patient lies on the abdomen and turns the brought up to the abdomen.
head to either side. A small pillow may be ♦ Draping can be done with one large sheet or
placed under the head. two small sheets that meet at the rectal area. A
♦ The arms may be flexed at the elbows and sheet with a hole at the examination site may
positioned on either side of the head or posi- also be used. All sheets hang free at the sides.
tioned along the side of the body.
Knee–Chest Position
♦ This position is used for rectal examinations,
usually a sigmoidoscopic examination (figure
20-14).
♦ The patient rests the body weight on the knees
and chest.
♦ The arms are flexed slightly at the elbows and
are extended above the head.
♦ The knees are slightly separated, and the
thighs are at right angles to the table.
FIGURE 20-11 Horizontal recumbent (supine)

position. Draping has been omitted for clarity.
FIGURE 20-12 Prone position. FIGURE 20-13 Sims’ (left lateral) position.
FIGURE 20-14 Knee–chest position. FIGURE 20-15A Semi-Fowler’s (mid-Fowler’s)

position.
♦ Draping can be done with one large sheet or

two small sheets that meet at the rectal area. A
large sheet with a hole at the rectal area can
also be used. Sheets hang loose with no
tucks.
CAUTION: Do not place the patient in this
position until the physician is ready to begin
the examination.
CAUTION: Never leave a patient alone in
this position. This is a difficult position for
the patient to maintain and should be used FIGURE 20-15B High Fowler’s position.
only as long as absolutely necessary.
Fowler’s Positions Lithotomy Position
♦ These positions are used to facilitate breath- ♦ This position is used for vaginal examinations,
ing, relieve distress, encourage drainage, and Pap tests, urinary catherization, cystoscopic
examine the head, neck, and chest. examinations, and surgery of the pelvic area
♦ The patient lies on the back. (figure 20-16).
♦ The head is elevated to one of three main ♦ The patient is positioned on the back.
positions: ♦ The knees are separated and flexed, and the
(1) Low Fowler’s: the head is elevated to a 25- feet are placed in stirrups.
degree angle.
(2) Semi-Fowler’s: the head is elevated to a 45- ♦ The arms rest at the sides.
degree angle (the most frequently used ♦ The buttocks are at the lower end of the table.
position) (figure 20-15A). ♦ The lower end of the table is dropped down or
(3) High Fowler’s: the head is elevated to a 90- pushed in depending on the model of the
degree angle (figure 20-15B). examination table.
♦ The legs lie flat on the table but the knees are ♦ Draping is done with one large sheet placed
bent slightly and are sometimes supported on over the body in a diamond shape. One corner
a pillow. is at the upper chest, and one corner hangs
♦ One sheet is used to drape the patient. The loose between legs. Each of the other two cor-
sheet is left hanging loose. ners is wrapped around a foot.
728 CHAPTER 20
FIGURE 20-18 Surgical Trendelenburg position.

FIGURE 20-16 Lithotomy position.
on the back. The table is lowered at a 45-
Dorsal Recumbent Position degree angle to lower the head, and the feet
♦ This position is similar to the lithotomy posi- and lower legs are inclined downward.
tion, but the patient is in bed or on a table ♦ Straps are frequently used to hold the patient
without stirrups (figure 20-17). in position.
♦ The feet are separated but flat on the table/ NOTE: Draping for the Trendelenburg position
bed. depends on the treatment being performed; usu-
♦ The knees are bent. ally, one large sheet is used and left hanging loose.
♦ Draping and other points are the same as for For surgical procedures, the patient is draped
the lithotomy position. with a sheet that has a hole to expose the surgical
area.
Trendelenburg Position Jackknife (proctologic) Position
♦ This position increases circulation of blood to ♦ This position is used mainly for rectal surgery
the head and brain, and can be used for circu- or examinations and for back surgery or treat-
latory shock. The entire bed or table is elevated ments (figure 20-19).
at the feet. The patient lies in the horizontal
recumbent position, with the head lower than ♦ The patient is in the prone position.
the feet. ♦ The table is elevated at the center so that the
♦ The surgical Trendelenburg position (figure rectal area is at a higher elevation. A special
20-18) can be used for surgery on pelvic organs surgical table is required for this position.
and for pelvic treatments. The patient is flat
FIGURE 20-17 Dorsal recumbent position. FIGURE 20-19 Jackknife (proctologic) position.
♦ The head and chest point downward. The feet area. Two small sheets that meet at the surgi-
and legs hang down at the opposite end of the cal or treatment area can also be used.
table. CAUTION: It is important to use good body
♦ The patient must be supported to prevent mechanics while positioning the patient to
injury. Straps are used to hold the patient in protect both yourself and the patient.
position.
♦ Draping is done with a surgical sheet that has the assignment sheet for 20:2, Positioning a Patient.
a hole to expose the surgical or treatment Then return and continue with the procedure.
PROCEDURE 20:2
b. Place a small pillow under the head.
Positioning a Patient
c. Rest the arms at the sides of the
body.
d. Position the legs flat and slightly sep-
Two to three sheets or disposable drapes, arated.
examination table, patient gown, two small
pillows e. Use a large sheet or drape to drape
the patient. Do not tuck the sheet in
Procedure at the sides or bottom. It should hang
loose.
1. Assemble equipment. Prepare the 7. Position the patient in the prone posi-
examination table by wiping it with a tion as follows:
disinfectant and covering it with table
a. Ask the supine patient to turn the
paper.
body in your direction until lying on
2. Wash hands. the abdomen. Hold the drape up
3. Introduce yourself. Identify the patient. while the patient is turning.
Explain the procedure. Obtain the CAUTION: Watch the patient closely to
patient’s consent. make sure he or she does not roll off of
4. Instruct the patient to remove all cloth- the table. Do not leave the patient
ing and to put on an examining gown. alone.
Instruct the patient to leave the opening b. Turn the head to either side to rest on
in the front or the back depending on a small pillow.
the examination to be performed. Ask
c. Flex the arms at the elbows and place
the patient to void to prevent bladder
at the sides of the head.
discomfort during the examination or
treatment. d. Use one large sheet or drape to drape
the patient. Do not tuck in at the
5. Help the patient get on table.
sides or bottom.
NOTE: Positioning of the patient will
8. Position the patient in the Sims’ (left lat-
depend on the examination, treatment,
eral) position as follows:
or procedure to be performed.
a. Ask the prone patient to turn on the
6. Position the patient in the horizontal
left side.
recumbent (supine) position as follows:
b. Extend the left arm behind the back.
a. Lay the patient flat on his or her
back. c. Rest the head on a small pillow.
730 CHAPTER 20
PROCEDURE 20:2
d. Bend the left leg slightly. any such signs immediately after
being sure that the patient is in a
e. Bend the right leg sharply to the
comfortable, safe position.
abdomen.
10. Position the patient in the Fowler’s posi-
f. Place the right arm bent at the elbow
tions as follows:
in a comfortable position in front of
the body. a. Place the patient in the horizontal
recumbent position.
g. Drape with one large sheet or drape.
Do not tuck in at the sides or bottom. b. Place a small pillow under the
Draping can also be done with two patient’s head.
small sheets. One sheet covers the
c. Low Fowler’s: elevate the head of the
upper part of the body and meets the
table/bed to a 25-degree angle.
second sheet, which covers the thighs
and legs. A sheet with an opening at d. Mid-, or semi-, Fowler’s: elevate the
the rectal area may also be used. head to a 45-degree angle.
9. Position the patient in the knee–chest e. High Fowler’s: elevate the head to a
position as follows: 90-degree angle.
a. Ask the patient to lie on the abdomen f. Place a second small pillow under the
(that is, in the prone position). patient’s knees after flexing them
slightly.
b. Raise the buttocks and abdomen
until the body weight is resting on g. Use a large sheet or drape to drape
the upper chest and knees. the patient. Do not tuck in the sides
or end of the sheet or drape.
NOTE: Do not place the patient in this
position until the physician is ready to 11. Position the patient in the lithotomy
begin the examination. It is a difficult position as follows:
position for the patient to maintain. a. Position the patient on the back with
c. Make sure the knees are slightly sep- the arms at the sides. The feet should
arated and the thighs are at right be resting on the extension at the
angles to the table. lower end of the table.
d. Rest the head on a small pillow. b. Ask the patient to slide the buttocks
down on the table to where the lower
e. Flex the arms slightly and position on
end of the table folds down or pulls
the sides of the head.
out.
f. Drape with one large, untucked sheet
c. Position a small pillow under the
or drape or two small sheets or drapes
patient’s head.
that meet at the rectal area. A drape
with a hole at the rectal area can also d. Place a sheet or drape over the patient
be used. in a diamond position. One corner
should be at the chest, the opposite
CAUTION: Never leave the patient alone
corner at the perineal area, or
in the knee–chest position.
between the legs. Wrap each side
g. When the examination is complete, corner around a foot.
help the patient get into the prone
e. Position the stirrups and lock them
position. Watch closely for signs of
in place.
dizziness or discomfort and report
PROCEDURE 20:2
NOTE: Many tables have a knob at the
side that is turned to lock the stirrups in
position.
f. Flex and separate the knees.
g. Place the feet in the stirrups.
h. Drop the lower end of the table, or
push in the extension.
i. To get the patient out of this position,
first raise the end of the table or pull
out the extension so that it is level.
Lift the feet out of the stirrups and
place them on the table. Ask the
patient to move back up on the
table.
12. Position the patient in the Trendelen-
burg positions as follows:
NOTE: These positions require a special
bed or table and assistance. Care should
be taken to prevent the patient from
sliding off the table.
a. Put the patient in the horizontal
recumbent position.
b. Operate the power table or electric
bed to raise the foot of the bed so that
the patient’s head is lower than the
rest of the body. The lower frame of
the bed is sometimes supported up
on blocks.
c. For the surgical Trendelenburg posi-
tion, lower the bottom end of the
table so that the lower legs are
inclined at a downward angle.
d. Use one large or two small sheets or
drapes to drape the patient, or use a
drape with a hole at the surgical site.
e. Use straps to secure the patient in FIGURE 20-20 A special power table is
position. required for the jackknife or proctologic position.
(Courtesy of Midmark Corp.)
f. Remain with the patient at all times.
13. Position the patient in the jackknife or
protologic position as follows:
NOTE: This position requires a special
table and assistance (figure 20-20).
732 CHAPTER 20
PROCEDURE 20:2
Care must be taken to prevent the necessary. Inform the patient of how
patient from sliding off the table or and when he or she will be notified of
being injured in any way. test results (if tests were conducted dur-
ing the examination).
a. Position the patient in the prone
position. CAUTION: Watch the patient closely
and prevent falls.
b. Secure the safety straps on the table.
c. Lower the top of the table so that the
head and upper body are inclined at 17. Wash hands.
a downward angle.
d. Lower the bottom of the table so that patient’s chart; for example, date, time,
the feet and legs are inclined at a positioned in semi-Fowler’s for comfort,
downward angle. appears to be resting well, and your sig-
nature and title.
e. Use a large sheet or special drape that
has an opening in it to cover the
patient. Place the opening over the
rectal area. You may also use two
small sheets that meet at the rectal
area. Practice
f. Remain with the patient at all times. evaluation sheet for 20:2,
Observe for any negative reactions to Positioning a Patient, to practice
the position, such as dizziness, pain, this procedure. When you believe
or discomfort. Immediately report
any such signs to your supervisor.
14. When the examination, treatment, or instructor for further action.
procedure is complete, allow the patient
to sit up. Observe for signs of dizziness
or weakness.
15. Help the patient get off the table. Ask listed on the evaluation sheet, your
the patient to get dressed or assist if instructor will grade your performance.
eyes. If defects are noted on any test, the patient

20:3 INFORMATION should be referred to an ophthalmologist for a
more extensive examination.
Screening for Vision Problems One method of vision screening involves the
Vision screening tests are given to measure an use of Snellen charts. Snellen charts are used to
individual’s visual acuity, or ability to perceive test distant vision (figure 20-21). They come in a
and comprehend the sense of sight. They are variety of types. Some contain pictures for use
often given as part of a physical examination or with small children. Some contain the letter E in
to detect eye disease. Any test for visual acuity a variety of positions. The patient points in the
should be conducted in a well-lighted room. Nat- direction that the E points. This type of chart is
ural daylight, with no direct sunlight, is preferred. used for non-English-speaking people or non-
During any test, it is important to watch the readers. Some contain letters of the alphabet. It is
patient for squinting, leaning toward the eye important to make sure the patient knows all the
chart, closing one eye when both eyes are being letters of the alphabet when using this type of
tested, excessive blinking, and/or watering of the chart.
It is important to note that Snellen charts test

only for defects in distant vision, or for nearsight-
edness (myopia). Defects in close vision (prob-
lems with reading small print and seeing up
close), known as farsightedness (hyperopia), are
tested by the Jaeger system. This system uses a
printed card with different short paragraphs.
Each paragraph is printed in a different size type,
ranging from 0.37 to 2.5 millimeters (mm) high. A
card with different characters or pictures is avail-
able for use with small children or individuals
who cannot read. The patient holds the card
approximately 14–16 inches away from the eyes
(figure 20-22). The patient then reads printed text
or identifies pictures that gradually become
smaller. The smallest print or character that the
patient can read or identify without error is
recorded.
Defects in color vision, or color blindness, are
FIGURE 20-21 Snellen charts are used for vision usually tested by the Ishihara method. The Ishi-
screening. hara book contains a series of numbers printed
in colored dots against a background of dots in
contrasting color (figure 20-23). Patients with
Characters (that is, letters or pictures) on the
Snellen chart have specific heights, ranging from
small, on the bottom of the chart, to large, on the
top of the chart. When standing 20 feet from the
chart, a person with normal visual acuity should
be able to see characters that are 20 millimeters
high. Such a person is said to have 20/20 vision.
When referring to 20/20 vision, the top number
represents the distance the patient is from the
chart. For this screening test, then, the patient is
placed 20 feet from the chart. The bottom num-
ber represents the height of the characters that
the patient can read at that distance.
♦ Example 1: If a patient has 20/30 vision, this
means that when standing 20 feet from the FIGURE 20-22 The patient holds the card 14–16
chart, the patient can see characters 30 milli- inches from the eyes when testing for defects in
meters (mm) high. It can also be stated that close vision.
this patient, who is standing 20 feet from the
chart, can see what a patient with normal
visual acuity can see standing 30 feet from the
chart.
♦ Example 2: If a patient has 20/100 vision, this
means that when standing 20 feet from the
chart, the patient can only see characters that
are 100 millimeters (mm) high. This finding
represents a defect in distant vision. A person
with normal visual acuity would be able to see FIGURE 20-23 People with color blindness are
the same figures while standing 100 feet from not able to see the numbers in these Ishihara color
the chart. plates.
734 CHAPTER 20
normal color vision are able to readily identify ♦ Myopia: nearsightedness, defect in distant
the numbers. Patients with color blindness either vision
are unable to see the numbers or identify incor-
rect numbers. This test is most accurate when it is
♦ Hyperopia: farsightedness, defect in close
vision
conducted in a room illuminated by natural day-
light but not by bright sunlight. ♦ Ophthalmoscope: instrument for checking
When screening for visual acuity, there the eye
are some special terms or abbreviations to ♦ Tonometer: instrument to measure intraocu-
remember: lar tension or pressure; increased pressure
♦ OD: abbreviation for oculus dexter, or right often indicates glaucoma
eye
♦ OS: abbreviation for oculus sinister, or left eye the assignment sheet for 20:3, Screening for Vision
♦ OU: abbreviation for oculus uterque, or each Problems. Then return and continue with the pro-
eye; both eyes cedure.
PROCEDURE 20:3
sure small children know what each pic-
Screening for Vision ture represents.
Problems 5. Instruct the patient to stand facing the
chart. Make sure the patient’s toes are
Equipment and Supplies on the taped line; the patient’s eyes will
be 20 feet from the chart.
Snellen eye chart, Jaeger card, Ishihara book
with color plates, pointer, tape, eye shield or 6. Point to various letters or pictures on
occluder, paper, pen or pencil the chart. Ask the patient to identify the
letters or pictures. If the patient wears
Procedure corrective lenses (glasses or contact
lenses), check the vision with the cor-
1. Assemble equipment. Check the light- rective lenses first. Then ask the patient
ing in the room to make sure there is no to remove the corrective lenses. Check
glare. Natural daylight is preferred. the vision again. Record both readings.
Observe the following points:
2. Attach the Snellen chart to the wall or
place it in a lighted stand. Measure a a. Start with the larger letters or pictures
distance of 20 feet directly away from and proceed to the smaller ones.
the front of the chart. Place a piece of b. Make sure the pointer you are using
tape on the floor at the 20-foot mark. does not block the letters or pic-
NOTE: Most medical offices will have a tures.
mark on the floor to indicate the 20-foot c. Select letters or pictures at random in
distance. each row. Do not start at one end of
3. Wash hands. the row and go straight across the
line. Patients may memorize order;
random sampling makes the patient
focus on individual letters or pic-
NOTE: If using a chart with letters, make tures.
sure the patient knows the letters of the
alphabet. If using a picture chart, make
PROCEDURE 20:3
NOTE: If you are sure the patient has
not memorized the letters, you may ask
the patient to read a row of letters. If the
patient is able to read all letters cor-
rectly, proceed to a smaller row.
d. Watch to be sure the patient is not
leaning forward or squinting to see
the letters or pictures (figure 20-24A).
Note whether the patient is blinking
excessively or if the eyes are water-
ing.
NOTE: Some examiners do the left or
right eye first, the opposite eye second,
and both eyes last. Follow your agency’s FIGURE 20-24B The patient should keep the
policy. eye open while covering it with an eye shield or
7. Ask the patient to correctly identify all occluder.
the letters or pictures in the 20/20 line.
If the patient is unable to do so, note the the left eye while it is covered, because
line that the patient can read with 100- doing so can cause blurred vision.
percent accuracy. Repeat steps 6 and 7 to test the vision in
the right eye (OD).
8. Give the patient an eye shield or occluder
with which to cover the left eye (figure CAUTION: Warn the patient against
20-24B). Warn the patient not to close pressing on the covered eye to avoid
injuring the eye with the occluder or
shield. Do not use the occluder or shield
on another patient until it has been dis-
infected. Some occluders are dispos-
able.
9. Ask the patient to cover the right eye.
Repeat steps 6 and 7 to test the vision in
the left eye (OS).
NOTE: Remind the patient to keep the
right eye open while it is covered.
10. Record the test results for both eyes, the
right eye, and the left eye. Use abbrevia-
tions of OU, OD, and OS and readings of
20/20, 20/30, or the correct reading.
11. To test vision by the Jaeger system:
a. Seat the patient in a comfortable
position.
b. Ask the patient to hold the Jaeger
card 14–16 inches from the eyes.
FIGURE 20-24A Watch to make sure the
patient is not leaning forward or squinting to see c. Ask the patient to read the paragraphs
the letters. out loud.
736 CHAPTER 20
PROCEDURE 20:3
NOTE: If the patient cannot read, pro- determine which type of color blind-
vide a Jaeger card that contains charac- ness the patient has.
ters or pictures.
13. Thank the patient for being coopera-
d. Record the smallest line of print the tive.
patient can read with both eyes.
NOTE: These are only screening tests.
e. Ask the patient to cover the right eye Unfavorable results indicate the need
with an occluder and then to read the for additional testing or referral to an
paragraphs out loud. Record the eye specialist.
smallest line of print the patient can
14. Clean and replace all equipment. If the
read with the left eye.
eye shield is not disposable, wash it
f. Ask the patient to cover the left eye thoroughly and clean it with a disinfec-
with an occluder and then to read the tant solution.
paragraphs out loud. Record the
15. Wash hands.
smallest line of print the patient can
read with the right eye. 16. Record all required information on the
12. To test color vision with the Ishihara
example, date; time; vision screening
plates:
with Snellen chart: OU 20/30, OD 20/40,
a. Seat the patient in a comfortable OS 20/30; Jaeger card: OU #3 (0.62m),
position. OD #3 (0.62m), OS #5 (1.00m); Ishihara
plates: 10 plates correct for OU, OD, and
b. Hold the plate approximately 30
OS; and your signature and title.
inches from the patient’s eyes.
c. Ask the patient to read the number
on the plate.
NOTE: Some plates contain color lines
in place of numbers. The patient is asked
to trace the color line with a finger.
d. Show the patient all of the plates.
Record the number of plates the Practice
patient identifies correctly. Go to the workbook and use the
evaluation sheet for 20:3, Screening
e. Ask the patient to cover the right eye for Vision Problems, to practice this
with an occluder and then to identify
the numbers on the plates. Record
the number of plates the patient
identifies correctly with the left eye.
for further action.
f. Ask the patient to cover the left eye
with an occluder and then to identify
the numbers on the plates. Record
the number of plates the patient
identifies correctly with the right
eye.
g. Report any frame that the patient listed on the evaluation sheet, your
misses. This allows the physician to instructor will grade your performance.
20:4 INFORMATION
Assisting with Physical
Examinations
A large variety of physical examinations are per-
formed. The methods used and the equipment
available vary from physician to physician. How-
ever, there are some basic principles that apply to
all examinations.
Three major kinds of examinations are:
♦ EENT: This is an eye, ear, nose, and throat
examination. Special equipment should be
available to examine these areas of the body.
♦ GYN: This is an examination of the female
reproductive organs; that is, a gynecological
examination. The physician usually examines
the vagina, cervix, and other pelvic organs as
well as the breasts. A Pap, or Papanicolaou, FIGURE 20-25 The physician uses observation
test frequently is done to detect cancer of the to inspect the body for signs of disease.
cervix or reproductive organs.
♦ General, or complete, physical: All areas of the
body are examined. Blood and urine tests fre-
quently are done. Radiographs and an electro-
cardiogram (ECG) may also be part of the
examination. An EENT and/or GYN examina-
tion may be performed. Necessary equipment
and tests are determined by the physician per-
forming the examination.
Four main techniques used during the exam-
ination are observation, palpation, percussion,
and auscultation.
♦ Observation (inspection): The physician looks
at the patient carefully to observe things such as
skin color, rash, growths, swelling, scars, defor-
mities, body movements, condition of hair and
nails, and general appearance (figure 20-25).
♦ Palpation: The physician uses the hands and FIGURE 20-26 For palpation, the physician uses
fingers to feel various parts of the body (figure the hands and fingers to feel various parts of the
20-26). The physician can determine whether body.
a part of the body is enlarged, hard, out of
place, or painful to the touch. ♦ Auscultation: The physician listens to
sounds coming from within the patient’s body
♦ Percussion: The physician taps and listens
(figure 20-28). A stethoscope is used in most
for sounds coming from various body organs
cases. The physician listens to sounds pro-
(figure 20-27). The physician may place one or
duced by the heart, lungs, intestines, and other
several fingers of one hand on a part of the
body organs.
body, then use the fingers of the other hand to
tap the body part. The sounds emitted allow a All necessary equipment should be assem-
trained individual to determine the size, den- bled prior to the examination. The equipment
sity, and position of underlying organs. needed will vary depending on the body areas to
738 CHAPTER 20
FIGURE 20-27 Percussion involves tapping on

body parts and listening to sounds coming from
body organs.
FIGURE 20-28 The physician is using a stetho-
scope and auscultation to listen to posterior lung
and heart sounds.
be examined. Try to anticipate what the physi-

cian will need, and assemble the items for conve-
nient use. Some of the equipment and instruments
used for different examinations (figure 20-29) is used to examine the nose; a vaginal specu-
include: lum is used to examine the vagina; a rectal
speculum is used to examine the rectum
♦ Cervical spatula (Ayer blade): a wooden or
plastic blade used to scrape cells from the cer-
♦ Sphygmomanometer: an instrument used
to measure blood pressure
vix, or lower part of the uterus; it is usually a
part of a Pap kit that also contains slides, ♦ Stethoscope: an instrument used for listen-
swabs, and a cytology brush; used to perform ing to internal body sounds
a Pap test to check for cancer of the cervix ♦ Tongue blade/depressor: a wood or plastic
♦ Laryngeal mirror: an instrument with a stick used to depress, or hold down, the tongue
mirror at one end; used to examine the larynx, so that the throat can be examined
or voice box, in the throat ♦ Tuning fork: an instrument with two prongs
♦ Ophthalmoscope: a lighted instrument that is used to test hearing acuity
used to examine the eyes (figure 20-30) Preparation of the patient must include
♦ Otoscope: a lighted instrument used to carefully explaining all procedures. Thor-
examine the ears (figure 20-31A and B) ough explanations can help alleviate some fear.
♦ Percussion (reflex) hammer: an instru- Patients often are apprehensive and need reas-
ment used to test tendon reflexes surance. The patient usually must remove all
clothing and put on an examining gown. It is
♦ Sigmoidoscope: a lighted instrument used important to tell the patient to void before the
to examine the sigmoid colon, or inside of the examination so that the bladder will be empty
lower part of the large intestine; used during and internal organs in the area of the bladder can
sigmoidoscopic examinations be palpated. If a urinalysis is ordered, the urine
♦ Speculum: an instrument used to examine specimen can be obtained at this time. Correct
internal canals of the body; a nasal speculum positioning and draping is also essential.
1 10
8
9
2
4
23
3
11 12 13
14 24
15 17 20
18 25
19
5 16 26
7 21
27
6
22
FIGURE 20-29 Instruments and equipment for physical examinations. 1. Tuning fork. 2. Visual occluder.
3. Ruler. 4. Visual acuity chart. 5. Reflex hammer with brush. 6. Percussion hammer. 7. Pen and marking pen.
8. Penlight. 9. Thermometer. 10. Sphygmomanometer. 11. Slide and fixative. 12. Specimen cup. 13. Vaginal
speculum. 14. Lubricant. 15. Goniometer to measure angles. 16. Gloves. 17. Cervical spatula (Ayer blade).
18. Cervical brush (cytobrush). 19. Cotton-tip applicator. 20. Tongue depressor. 21. Guaiac material for fecal
occult blood. 22. Tape measure. 23. Stethoscope. 24. Ophthalmoscope. 25. Otoscope. 26. Neurological
examination key and cotton ball. 27. Sterile needle.
Some tests frequently done prior to the phys- ♦ Blood tests: various tests may be ordered by
ical examination might include the following: the physician
♦ Height and weight: record all information ♦ Electrocardiogram: a test to check the electri-
accurately cal conduction pattern in the heart; performed
♦ Vital signs: including TPR (temperature, pulse, if ordered by the physician
respiration) and BP (blood pressure); record
all information accurately During the examination, be prepared to assist
as necessary. Hand equipment to the physician
♦ Vision screening: test as previously instructed as needed. Position the patient correctly for each
♦ Audiometric screening: a special hearing test part of the examination. Pay attention so that you
requiring additional training to administer are ready to help with each procedure.
740 CHAPTER 20
FIGURE 20-30 An ophthalmoscope is used to FIGURE 20-31B An otoscopic examination may

examine the patient’s eye. reveal a bulging tympanic membrane, a sign of otitis
media or middle ear infection. (Courtesy of Bruce
Black, MD, Brisbane, Australia)
Standard precautions (discussed in Chapter

14:4) must be followed at all times while
assisting with physical examinations. Hands
must be washed frequently, and gloves must be
worn if contact by blood or body fluids is likely. If
splashing or spraying of blood or body fluids is
possible, other personal protective equipment
(PPE) such as a mask, eye protection, and/or a
gown must be worn. Any instruments or equip-
ment contaminated by blood or body fluids must
be correctly cleaned and disinfected or sterilized
after use. The medical assistant must always be
aware of and take steps to prevent the spread of
infection.

the assignment sheet for 20:4, Assisting with Phys-
FIGURE 20-31A An otoscope is used to examine ical Examinations. Then return and continue with
the interior of the patient’s ear. the procedures.
30216_20_Ch20_715-778.indd 740 1/16/08 1:45:24 PM

PROCEDURE 20:4A
7. Notify the physician that the patient is
Eye, Ear, Nose, and ready. Have disposable gloves available
Throat Examination for the physician to use. The physician
may put the gloves on at the start of the
NOTE: This is a basic guideline. Methods and examination or at the point during the
equipment will vary from physician to physi- examination when contact with body
cian. fluids may occur.
8. Eyes are usually examined first. Turn the
Equipment and Supplies ophthalmoscope light on and hand the
Tray covered with a towel, basin lined with a ophthalmoscope to the physician. When
paper towel, cotton-tipped applicators, oph- the physician hands the ophthalmo-
thalmoscope, otoscope, tonometer, tuning scope back, turn the light off because it
fork, nasal speculum, laryngeal mirror, glass is easier to check the pupil’s reaction to
of warm water, tongue blades or depressors, light.
flashlight or penlight, Snellen chart, culture NOTE: Some physicians want the room
tubes and slides (as needed), disposable light turned off during the eye examina-
gloves, infectious-waste bag, patient’s chart, tion.
lab requisition forms, pen or pencil 9. The nose is usually examined next. Have
the nasal speculum and penlight ready
Procedure for use. Also have cotton-tipped appli-
cators ready. If a culture is taken, handle
1. Assemble equipment. Arrange the
the culture stick correctly.
instruments on a Mayo stand or tray.
NOTE: Refer to Procedure 19:2A, Obtain-
2. Wash hands. Put on gloves for any pro-
ing a Culture Specimen, if necessary.
cedure that involves contact with blood
or body fluids. 10. The ears are usually examined next. Pass
the otoscope with its light on to the phy-
sician. Have a cotton-tipped applicator
tions at all times.
ready for use. When the examination is
3. Introduce yourself. Identify the patient. done, turn off the otoscope light. Place
Explain the procedure. Remember that the otoscope tip in the towel-lined
this procedure has multiple steps. basin. If the physician wants to test
4. Screen for visual acuity with a Snellen hearing acuity, hand the physician the
chart, Jaeger card, and/or Ishihara plates tuning fork. Hold the tuning fork in the
as required. Record all results accu- middle so the physician can grasp it at
rately. the stem end. The physician will check
auditory acuity (hearing) with the tun-
5. Place the patient in a sitting position.
ing fork (figures 20-32A–C).
NOTE: If an eye, ear, nose, and throat
11. The mouth and throat are usually exam-
examination (EENT) is the only exami-
ined last. Pass the tongue blade or
nation being done, the patient can
depressor by holding it in the center.
remain dressed.
Turn on the penlight and hand it to the
6. Ask the patient to remove glasses and/ physician, as needed.
or hearing aid(s). Tell the patient to
place these items in a safe place. 12. Have culture sticks and tubes available.
Hand these to the physician correctly.
NOTE: Hearing aids are sometimes not
CAUTION: Avoid contaminating the tip
removed until the actual ear examina-
of the culture stick.
tion. This is particularly true if the
patient cannot hear questions without a 13. If a laryngeal mirror is used for a more
hearing aid. thorough examination of the throat and
742 CHAPTER 20
PROCEDURE 20:4A
FIGURE 20-32A The FIGURE 20-32B The FIGURE 20-32C The

physician places the vibrating physician can also test auditory physician can also check bone
tuning fork on the top of the acuity by placing the vibrating conduction of sound by placing
head to ascertain whether both tuning fork about 1–2 inches the tuning fork on the mastoid
ears can hear the sound. away from each ear. bone behind the ear.
larynx, warm the mirror end by placing ment. Put all contaminated disposable
it in a glass of warm water. Dry the mir- supplies in the infectious-waste bag.
ror and hand it to the physician. Use a disinfectant to wipe any contami-
NOTE: This prevents fogging during nated areas.
use. 19. Remove gloves and discard in an infec-
14. Place the used mirror in the towel-lined tious-waste bag. Wash hands.
basin. 20. Record all required information on the
15. Take hold of the used tongue depressor patient’s chart, for example, date, time,
in the center. Without touching either EENT examination, throat culture sent
end, place it in the infectious-waste bag. to lab, and your signature and title. Place
a copy of any lab requisitions in the
16. When the examination is complete, help
patient’s chart. The physician some-
the patient replace glasses, hearing
times records the required information.
aid(s), and so forth. Help the patient get
off the examination table. Inform the
patient of how and when he or she will
be notified of test results.
17. Label all specimens correctly with the
Practice
patient’s name, identification number,
and doctor’s name. Print all information evaluation sheet for 20:4A, Assisting
on the lab requisition form. This might with an Eye, Ear, Nose, and Throat
include date, time, patient’s name, Examination, to practice this
address, identification number, doctor’s procedure. When you believe you
name and identification number, type have mastered this skill, sign the
or site of specimen, and test ordered. sheet and give it to your instructor
Send all specimens to the laboratory as for further action.
soon as possible.
18. Clean and replace all equipment. Put on Final Checkpoint Using the criteria
gloves while disinfecting and sterilizing listed on the evaluation sheet, your
contaminated instruments or equip- instructor will grade your performance.
PROCEDURE 20:4B
Assisting with a Explain the procedure. Remember that
Gynecological this procedure has multiple steps.
Examination 4. Ask the patient to void. If a urinalysis is

ordered, obtain the urine specimen at
NOTE: The equipment and steps of this pro- this time.
cedure can vary from physician to physician. NOTE: An empty bladder makes it easier
for the physician to palpate the uterus.
Equipment and Supplies 5. Ask the patient to remove all clothing
Tray covered with a towel, sheet or drape, and put on an examination gown. The
patient gown, cotton-tipped applicators; gown is usually open in the front to
sterile cotton-tipped applicators, gloves, facilitate the breast examination.
lubricant, vaginal speculum, cervical spatu-
6. Make sure the extension of the examin-
las (Ayer blades), cytology brush or ThinPrep
ing table is pushed in or dropped down.
test kit, culture tubes, slides and fixative,
Then assist the patient into a sitting
examining light, cotton balls, basin lined with
position on the table. Use the drape to
a paper towel, tissues, infectious-waste bag,
cover the patient’s lap and legs.
patient’s chart, lab requisition forms, pen or
pencil 7. Notify the physician that the patient is
ready for examination.
Procedure 8. The breasts are usually examined first.
After the physician has examined the
1. Assemble equipment and arrange on a breasts, place the patient in the hori-
tray or Mayo stand (figure 20-33). zontal recumbent position. Drape cor-
2. Wash hands. Put on gloves. rectly. The physician will usually
complete the breast examination at this
CAUTION: Gloves should be worn when
point.
any contact with vaginal secretions is
possible. NOTE: The patient should be taught
how to do a breast self-examination or
BSE (refer to figure 7-73). This can be
done before or after the examination.
Pamphlets describing the procedure,
available from the American Cancer
Society, can be given to the patient.
9. Place the patient in the lithotomy posi-
tion. Drape correctly. Position the exam-
ining light for proper lighting.
10. Warm the vaginal speculum by placing
it in warm water or rubbing it with a
clean towel. Hand the speculum in the
closed position to the physician. Be
ready to apply lubricant to the specu-
lum. Have cotton-tipped applicators
ready for use.
FIGURE 20-33 Basic equipment for a gyne-
cological examination.
744 CHAPTER 20
PROCEDURE 20:4B
NOTE: If a culture is to be taken, the d. Apply fixative to the slide(s). The fix-
lubricant may interfere with the organ- ative is usually a spray that is applied
ism. Lubricant is not placed on the to the entire slide. Sometimes the
speculum in such a case. entire slide is placed in a specimen
11. If a culture is to be taken, hand the ster- jar containing fixative solution.
ile applicator to the physician. Take care NOTE: Fixative makes the cells adhere
to avoid contaminating the tip. Have the (stick) to the slide until the slide is exam-
culture tube or slide available to receive ined.
the culture.
14. If a ThinPrep Pap test is being per-
12. If a Pap test is to be done, hand the phy- formed:
sician the cervical spatula (Ayer blade).
Grasp the blade in the center and place a. Grasp the cytology broom in the
the blunt end in the physician’s hand. middle as the physician hands it to
The V-shaped end is inserted in the you.
patient by the physician. b. Vigorously swish the cytology broom
NOTE: A cytology brush may be used in in the ThinPrep solution to wash the
place of or in addition to the cervical specimen off the brush.
spatula. Again, grasp the brush in the NOTE: This suspends the entire speci-
center, with the brush end directed men in the solution. At the laboratory,
toward the patient, to hand the brush to the solution will be processed to elimi-
the physician. nate blood cells, mucus, and any other
NOTE: If a ThinPrep Pap smear is being substances. The remaining cervical cells
done, hand the physician the cytology are then placed on a slide for examina-
broom from the test kit. tion. By eliminating other cells and
debris, the slide can be read much more
NOTE: A Pap test is done to detect can- accurately by either a computerized or
cer of the cervix. manual method.
13. If a conventional Pap test is being per-
c. Close the lid on the ThinPrep solu-
formed:
tion container.
a. Have a slide ready for use. The physi-
d. Discard the cytology broom in an
cian will place the smear on the slide
or hand the cervical spatula or cytol-
ogy brush to you. If the latter, spread 15. When the physician hands you the vagi-
the smear evenly and moderately nal speculum, place it in the towel-lined
thin on the slide. basin. If it is disposable, place it in the
NOTE: If the smear is too thick, the cells infectious-waste bag.
cannot be seen. 16. The digital (finger) examination is usu-
b. Put the cervical spatula or cytology ally done next. Place lubricant on the
brush in the infectious-waste bag. physician’s gloved fingers without
touching the gloves. The physician usu-
c. Frequently, two or three slides are ally does a digital examination of both
prepared: a cervical smear, a vaginal the vagina and rectum.
smear, and/or an endocervical smear.
Label each slide with the patient’s 17. When the examination is complete,
name and place a c on the cervical assist the patient out of the lithotomy
slide, a v on the vaginal smear, and an position. Offer tissue to the patient to
e on the endocervical smear. remove excess lubrication. Place the tis-
PROCEDURE 20:4B
sue in the infectious-waste bag. If no infectious-waste bag. Use a disinfectant
signs of weakness or dizziness are noted, to wipe any contaminated areas.
help the patient get off the table.
CAUTION: Watch the patient closely to tious-waste bag. Wash hands.
prevent falls.
18. Inform the patient how and when she patient’s chart; for example: date, time,
will be notified of test results. Ask the GYN examination, Pap smear sent to
patient to get dressed or assist with lab, and your signature and title. Place a
dressing if necessary. copy of any lab requisitions in the
patient’s chart. The physician some-
19. Completely label all cultures and slides
times records the required information.
with the patient’s name, identification
number, and doctor’s name. Print all
information on the lab requisition form.
This might include date, time, patient’s
name, address, identification number,
doctor’s name and identification num- Practice
ber, type or site of specimen, test Go to the workbook and use the
ordered, date of last menstrual period, evaluation sheet for 20:4B, Assisting
and information on any hormone ther- with a Gynecological Examination,
apy. Be sure you have all required infor- to practice this procedure. When you
mation before the patient leaves the believe you have mastered this skill,
office. sign the sheet and give it to your
20. Send all specimens to the laboratory as instructor for further action.
soon as possible.
21. Wear gloves while cleaning and steriliz-
ing the speculum and any contaminated Final Checkpoint Using the criteria
instruments or equipment. Put all con- listed on the evaluation sheet, your
taminated disposable supplies in the instructor will grade your performance.
PROCEDURE 20:4C
stethoscope, sphygmomanometer, ophthal-
Assisting with a moscope, otoscope, nasal speculum, tuning
General Physical fork, tongue depressors, laryngeal mirror,
glass with warm water, percussion hammer,
Examination new safety pin or sensory wheel, rectal spec-
ulum or proctoscope, Pap test kit and vaginal
NOTE: The equipment and steps of this pro-
speculum (female), culture tubes, slides, fixa-
cedure can vary from physician to physician.
tive solution, sterile applicators, lubricant,
alcohol swabs, gloves, penlight or examining
Equipment and Supplies light, infectious-waste bag, patient’s chart,
Tray or Mayo stand and cover, patient gown, lab requisition forms, pen or pencil
drape or sheet, basin lined with paper towels,
tissues, scale, Snellen chart, thermometer,
746 CHAPTER 20
PROCEDURE 20:4C
Procedure c. Use a Snellen chart to test visual acu-
ity; record results.
1. Assemble equipment. Arrange equip- d. Check visual acuity with a Jaeger card
ment conveniently on the Mayo stand and/or Ishihara plates; record
or tray (figure 20-34). results.
2. Wash hands. Put on gloves or have gloves e. Perform an audiometric screening if
available for later use. ordered.
CAUTION: Gloves should be worn any-
f. Run an electrocardiogram if ordered.
time contact with blood or body fluids is
possible. Observe standard precautions g. Obtain all required blood samples for
at all times. tests ordered.
3. Introduce yourself. Identify the patient. 6. Seat the patient on the examining table.
Explain the procedure. Remember that Drape the patient correctly.
this procedure has multiple steps. 7. Notify the physician that the patient is
4. Ask the patient to remove all clothing ready.
and put on an examining gown. Ask the
8. Assist with eye, ear, nose, and throat
patient to void. If a urinalysis is ordered,
examination as previously instructed.
collect the urine specimen at this time.
9. Give the physician the stethoscope and/
5. Do any of the required following proce-
or sphygmomanometer. Remain quiet
dures:
while the patient’s heart and lungs are
a. Record height and weight examined.
b. Take and record TPR (temperature, NOTE: The physician may check the
pulse, respiration) and/or BP (blood blood pressure.
pressure).
NOTE: The physician may also do an
initial examination of the breasts, legs,
and feet.
10. Place the patient in the horizontal
recumbent or supine position. Drape
correctly.
11. The physician will examine the chest
and abdomen. Draw the drape down to
the pubic area. Replace the drape after
the abdomen has been examined.
12. The legs and feet are examined next.
Have the percussion hammer ready. In
addition, have an open new safety pin
or sensory wheel ready in case the doc-
tor wants to use it to check sensation in
the feet.
13. The back and spine are usually exam-
ined next. Turn the patient to the prone
FIGURE 20-34 Equipment and supplies for a position and let the drape hang loose.
physical examination should be arranged in a
Assist as needed.
convenient order.
PROCEDURE 20:4C
NOTE: The back and spine can also be CAUTION: Watch closely to prevent
examined with the patient in a sitting falls.
position.
17. Label all specimens and cultures with
14. On a female patient, a vaginal examina- the patient’s name, identification num-
tion is usually done next. Put the patient ber, and doctor’s name. Print all infor-
in the lithotomy position. Drape cor- mation on the lab requisition form(s).
rectly. Assist as taught for a gynecological This might include date, time, patient’s
examination. The male patient can be name, address, identification number,
placed in the horizontal recumbent posi- doctor’s name and identification num-
tion for a genital organ examination. ber, type or site of specimen, and test
ordered. Send specimens to the labora-
NOTE: Male patients should be taught
tory as soon as possible.
how to do a testicular self-examination.
This can be done at this point or at the 18. Wear gloves while cleaning and steriliz-
end of the examination. ing any contaminated instruments or
equipment. Put all contaminated dis-
15. The rectal area is examined last in most
posable supplies in the infectious-waste
cases. A female can be examined while
bag. Use a disinfectant to wipe any con-
still in the lithotomy position or in the
taminated areas.
Sims’ position. A male is usually placed
in the Sims’ position. Hand gloves and 19. Remove gloves and discard in an infec-
lubricant to the physician, as needed. tious-waste bag. Wash hands.
Have the rectal speculum or anoscope
in a closed position ready for use. If the
patient’s chart; for example, date, time,
physician wants to check fecal occult
physical examination, throat culture
blood, put on gloves. Hand guaiac paper
and Pap smear sent to laboratory, and
to the physician.
your signature and title. Place a copy of
NOTE: The physician will place a small any lab requisition forms in the patient’s
amount of fecal material on the guaiac chart. The physician sometimes records
paper. To test the paper, add one to two the required information.
drops of hemoccult developing solution
to the paper. A color change indicates
the presence of blood in the stool.
CAUTION: Gloves must be worn any
time contact with fecal material is pos- Practice
sible. Go to the workbook and use the
16. When the examination is complete, evaluation sheet for 20:4C, Assisting
assist the patient into a sitting position with a General Physical
on the examination table. Allow the Examination, to practice this
patient to rest for a few minutes. If no procedure. When you believe you
signs of weakness or dizziness are noted, have mastered this skill, sign the
help the patient get off the table. Inform sheet and give it to your instructor
the patient how and when he or she will for further action.
be notified of test results. Ask the patient
to get dressed or assist with dressing if
necessary.
748 CHAPTER 20
Some basic instruments and supplies that may

20:5 INFORMATION be used (figure 20-35) include the following:
Assisting with Minor Surgery ♦ Scalpels: instruments with a handle attached
and Suture Removal to knife blades; used to incise (cut) skin and
tissue; disposable scalpels with a protective
As a health care worker, you may be required to retractable blade to prevent sharps injuries
prepare for and assist with minor surgery or are also available for use (figure 20-36)
suture removal in a medical, dental, or health
care facility. Minor surgery includes removing
♦ Surgical scissors: special scissors with blunt
ends or sharp points or a combination; identi-
warts, cysts, tumors, growths, or foreign objects;
fied as sharp-sharp, sharp-blunt, or blunt-
performing biopsies of skin growths or tumors;
blunt; used to cut tissue
suturing wounds; incising and draining body
areas; and other similar procedures. ♦ Hemostats: special group of curved or
Instruments and equipment used depend on straight instruments, usually striated at the
the type of surgery or procedure being done. ends; used to compress (clamp) blood vessels
to stop bleeding or grasp tissue
Surgical Bandage Hemostatic forceps

scissors scissors (curved or straight)
Needle holder
Suture needle
Scalpel blades and handles
Allis tissue forceps Tissue forceps

with teeth
FIGURE 20-35 Some sample surgical instruments. (Courtesy of Miltex, Inc.)

Plain Physician’s
splinter forceps splinter forceps
Jones Backhaus
towel clamp towel clamp
FIGURE 20-35, cont’d Some sample surgical instruments. (Courtesy of Miltex, Inc.)
surgical drapes to each other; also used to

clamp on to tissue that has been dissected
(separated or cut into pieces)
♦ Retractors: instruments used to hold or draw
back the lips, or sides, of a wound or incision;
also called skin hooks
♦ Suture materials: special materials used for
stitches (sutures); applied to hold a wound or
incision closed; absorbable suture material
such as surgical gut or vicryl is digested by tis-
sue enzymes and absorbed by the body; non-
FIGURE 20-36 Disposable scalpels with a absorbable suture materials such as silk,
protective retractable blade help prevent sharps nylon, Dacron, stainless steel, and metal skin
injuries. (Photo reprinted courtesy of BD [Becton, clips or staples are removed after the tissue or
Dickinson and Company]) skin has healed (figure 20-37)
♦ Tissue forceps: instruments with one or ♦ Needle holder: special instrument used to
more fine points (or teeth) at the tip of the hold or support the needle while sutures are
blades; used to grasp tissue being inserted
♦ Splinter forceps: instruments with fine- ♦ Needle: pointed, slender instrument with an eye
pointed ends and no teeth; used to remove at one end; used to hold suture material while
splinters and other foreign objects from the sutures are being inserted into an incision or
skin and/or tissues wound; usually curved for easier insertion into
♦ Towel clamps: instruments with sharp points the skin; swaged needles have the suture mate-
at the end that lock together; used to attach rial attached to the needle as one unit
750 CHAPTER 20
injection of local anesthesia, the physician may

apply a liquid or spray topical anesthetic to the
surface of the skin to decrease the pain of the
injection. Anesthetics must be available for use.
They are usually placed on the side of the sterile
tray. Sterile needles and syringes can be placed
on the surgical tray or kept in their packages by
the side of the tray.
During surgery, the medical assistant will be
expected to assist as needed. The procedure will
depend on the physician doing the surgery. Be
alert to all points of the procedure and be ready
to help as needed.
FIGURE 20-37 A wide variety of suture materials Sterile dressings must be available for use.
are available for minor surgeries.
These are usually placed directly on the surgical
tray so that they are readily accessible. Some phy-
sicians prefer that sterile dressings be left in the
original sterile wrappers and placed in the imme-
♦ Bandage scissors: special scissors with diate area.
blunt lower ends; used to remove dressings
Suture removal (removal of stitches) also
and bandages; the blunt ends prevent injury
requires that sterile technique be followed. Infec-
to the skin directly next to the dressing mate-
tion is an ever-present threat and must be pre-
rial
vented. Again, instruments and supplies will vary.
Preparation of the surgical tray requires the The main instruments used for this procedure
use of strict sterile technique to prevent infec- are suture scissors and thumb forceps (figure
tion. Instruments and supplies must be sterilized. 20-38). The two instruments are frequently pack-
Care must be taken to avoid contaminating the aged in sterilized, disposable kits called suture
instruments and supplies when they are placed removal sets. The thumb forceps is used to
on the tray. Complete sterile setups are also avail- grasp and hold the suture. It is compressed with
able in commercially prepared, disposable pack- the thumb and forefinger. The suture scissors
ages. Examples include setups for insertion of have a curved blade that is inserted under the
sutures and for removal of sutures. It is important suture material so that the stitch can be cut and
to follow sterile technique (see Chapter 14:8) removed. Basic guidelines are provided in Proce-
while opening the packages to maintain sterility dure 20:5B.
of all materials in the package. Before any minor surgery, the patient must
A skin prep is sometimes done before minor sign a written consent form. The consent form
surgery. This means that the surgical site is must describe the procedure, cite alternative
cleansed thoroughly with an antiseptic soap. If treatments, and list possible complications and/
the surgical area has excessive hair, the area may or risks of the surgery. If the patient is a minor or
be shaved. Shaving the surgical area is controver- is incompetent, an authorized person must sign
sial because shaving increases the risk for abra- the form. Most offices also provide written pre-
sions leaving open areas that are prone to operative and postoperative instructions.
infection. The person doing the skin prep should Patients who are undergoing minor surgery
wear gloves. The entire surgical area must be or suture removal are often fearful and
washed thoroughly with an antiseptic soap. If the apprehensive. Reassure the patient to the best of
site is shaved, the skin is held taut while a dispos- your ability. Refer specific questions regarding
able razor is used to shave in the direction of hair the surgery or procedure to the physician.
growth. It is important to avoid nicking the Body tissues, abnormal growths, and other
patient with the razor. The procedure is described specimens removed during surgery are usually
in detail in Procedure 21:13A. sent to a laboratory for examination. Each speci-
Before minor surgery, a local anesthetic is men must be placed in an appropriate container
often administered by the physician. This numbs immediately to avoid loss. A biopsy specimen is
the surgical site and decreases pain. Before the usually placed in a formalin solution that pre-
serves the specimen until it can be examined.

Most laboratories will provide a health care facil-
ity with the required specimen containers. The
containers must be labeled correctly, and the lab
requisition form must be filled in completely. The
specimens should be sent to the laboratory as
soon as possible.
Because contamination from blood and
body fluids is possible during minor surgi-
cal procedures, standard precautions (discussed
in Chapter 14:4) must be observed at all times.
Hands must be washed frequently, and gloves
must be worn. If splashing of blood or other body
fluids is possible, a gown, mask, and eye protec-
tion must be worn. Instruments and equipment
must be properly cleaned and sterilized after use.
Contaminated areas must be wiped with a disin-
fectant. Contaminated disposable supplies must
be placed in an infectious-waste bag prior to
being disposed of according to legal require-
ments. Sharp objects such as scalpel blades (or
disposable scalpels) and needles must be placed
in a leakproof puncture-resistant sharps con-
tainer immediately after use. The medical assis-
tant must always be aware of and take steps to
prevent the spread of infection.
FIGURE 20-38 A suture removal set consists of
suture scissors and thumb forceps. STUDENT: Go to the workbook and complete
the assignment sheet for 20:5, Assisting with Minor
Surgery and Suture Removal. Then return and
continue with the procedures.
PROCEDURE 20:5A
NOTE: All the following equipment should be
Assisting with Minor sterile: towels, drapes and towel clamps, two
Surgery to three pairs of sterile gloves, needle and
syringe, anesthetic medication, basin, anti-
NOTE: Instruments and procedures vary septic solution, gauze pads, scalpel and
depending on the type of surgery and the blades, surgical scissors, hemostat forceps
physician. (straight and curved), tissue forceps, retrac-
tors, needle holder, needle, suture material,
Equipment and Supplies and dressings (gauze and pads).
Tray with cover or Mayo stand, infectious-
waste bag, sharps container, personal protec-
Procedure
tive equipment (disposable gloves, mask, eye 1. Assemble equipment required.
protection, gown), tape, patient gown,
patient’s chart, lab requisition forms, pen or 2. Wash hands.
pencil
752 CHAPTER 20
PROCEDURE 20:5A
3. Check dates and sterilization indicators
on all sterile supplies to make sure the
supplies are still sterile. Make sure that
the package has not been wet and that
there are no tears or openings on the
wrap.
NOTE: Many sterile supplies are good
for 1 month only.
4. Place the tray or stand in an area where
there is freedom of movement and lim-
ited chance of contamination.
5. Open a sterile towel and place it on the
tray so that the entire tray is covered.
FIGURE 20-39 Instruments and supplies for
NOTE: Follow the correct procedure to
minor surgery should be arranged in a conve-
avoid contamination (see Chapter 14:8). nient order. Wrapped sterile items and nonster-
6. Open the other sterile towels or drapes ile items are placed by the tray.
and place them on the tray.
7. Open a sterile basin. Place it on the tray.
Put the sterile gauze in the basin. Obtain 9. Open the needle and syringe and place
the correct antiseptic solution and pour it on the tray. Unless the physician has
a small amount of the solution in a sink specified a certain size, have a variety of
or separate container to rinse the lip of needles of different gauges available.
the bottle. Then hold the solution bottle
approximately 6 inches above the sterile 10. Open the suture packages. Place them
basin and carefully pour the required on the tray. If specific sizes and types
amount of solution into the sterile have not been requested by the physi-
basin. cian, a variety of materials should be
made available.
NOTE: Read the label three times to be
sure you have the correct solution. 11. Place the sterile dressings on the tray.
The outer dressings should be placed on
CAUTION: Avoid handling the inside of the bottom of the pile. This way, the
the solution bottle cap. If the cap is dressings are in the order of use.
placed on a counter, make sure the open
end, or inside, is facing up. This prevents 12. Check the tray to be sure everything is
contamination of the inside of the cap. present. Use a sterile towel to cover the
tray.
CAUTION: Do not splash the solution
onto the tray. CAUTION: Do not leave the tray unat-
tended because contamination of the
8. Open all wrapped instruments and materials may occur.
place them on the tray in a convenient
order, usually the order of use (figure 13. Place the anesthetic solution, sterile
20-39). gloves, tape, and infectious-waste bag
close to the tray.
NOTE: Number and type of instruments
will depend on the type of surgery and NOTE: Several pairs of gloves should be
the physician. available in case one pair becomes con-
taminated.
PROCEDURE 20:5A
14. Introduce yourself. Identify the patient. c. The physician will apply sterile
Confirm that the patient observed all drapes. Have towel clamps ready for
preoperative instructions. Explain the the physician to use to hold the
procedure and preview postoperative drapes in position. The physician
orders. Ascertain that the patient has may cleanse the surgical site with an
signed a written consent form. antiseptic.
NOTE: If the patient is a minor or is d. When the physician is ready to inject
incompetent, an authorized person the anesthetic, use a gauze pad satu-
must sign the consent form. rated with alcohol to clean the top of
the anesthetic solution vial. Hold the
15. Ask the patient to empty the bladder,
vial in a convenient position so the
remove clothing as necessary for the
physician can fill the syringe (figure
procedure, and put on a patient gown.
20-40). The physician will then inject
Provide privacy for the patient or assist
the anesthetic. The needle and
if necessary.
syringe should be discarded immedi-
16. Take and record the patient’s vital signs. ately into a sharps container.
17. Position and drape the patient accord- e. If required, put on sterile gloves and
ing to the surgery to be performed. assist as needed. Hold retractors,
18. If necessary, prep the surgical site. Wash hand instruments, and assist with
hands and put on gloves. Wash the site the procedure.
thoroughly with an antiseptic soap. If a f. If tissue or a biopsy specimen is
skin shave has been ordered, hold the removed, open the lid of the speci-
skin taut and use a disposable razor to men container. Hold the container
shave in the direction of hair growth. close to the physician so the speci-
Discard long hairs on a gauze pad or men can be placed into the container
paper towel. Rinse the area and then pat (figure 20-41). Immediately close the
it dry with gauze. lid on the container.
CAUTION: Be careful not to nick the g. Get additional supplies or equipment
skin. as needed.
NOTE: Sometimes the physician prefers
to do the skin prep before the surgery.
Some minor surgeries will not require a
skin prep.
NOTE: The procedure for a skin prep is
discussed in detail in Procedure 21:13A.
19. During the surgery, assist as needed:
a. Uncover the tray when ready for use.
b. Give the sterile gloves to the physi-
cian.
CAUTION: If splashing of blood or body
fluids is possible, a gown, mask, and eye
protection must be worn. Observe all FIGURE 20-40 Hold the anesthetic solution
standard precautions while performing in a convenient position so the physician can fill
or assisting with minor surgery. the syringe without contaminating the needle.
754 CHAPTER 20
PROCEDURE 20:5A
22. Wear gloves to clean and sterilize all
instruments and equipment. Put sharp
objects such as the needle and syringe
and scalpel blade (or disposable scalpel)
in the sharps container immediately
after use. Put contaminated disposable
supplies in the infectious-waste con-
tainer. Use a disinfectant to wipe any
contaminated areas. Put all equipment
in its correct place.
patient’s chart; for example, date, time,
FIGURE 20-41 Tissue or biopsy specimens surgical removal of tumor on right
removed during minor surgery must be placed forearm, Specimen sent to pathology
in the correct type of specimen container so lab, verbal and written postoperative
they can be examined by a pathologist. instructions given to patient, and your
signature and title. Place a copy of any
lab requisitions in the patient’s chart.
20. After the surgery, assist as needed with The physician sometimes records the
placement of dressings and bandages. required information.
Observe for any signs of distress. If no
signs of weakness or dizziness are noted,
help the patient get off the table. Review
postoperative orders with the patient.
Provide the patient with a written copy
of postoperative orders if this is office
policy. Inform the patient how and when
he or she will be notified of test results.
21. Label all specimens correctly with the Practice
patient’s name, identification number, Go to the workbook and use the
and doctor’s name. Print all information evaluation sheet for 20:5A, Assisting
on the lab requisition form. This might with Minor Surgery, to practice this
include date, time, patient’s name, procedure. When you believe you
address, identification number, doctor’s have mastered this skill, sign the
name and identification number, type sheet and give it to your instructor
or site of specimen, and test ordered. for further action.
Make sure each specimen is in the cor-
rect specimen container or bottle. Check
the lids on the containers to make sure
they are closed securely. Send speci-
mens to the laboratory as soon as pos-
sible.
NOTE: Pathologists will provide special Final Checkpoint Using the criteria
containers for most health care facili- listed on the evaluation sheet, your
ties. instructor will grade your performance.
PROCEDURE 20:5B
Assisting with Suture
Removal
NOTE: The procedure for suture removal var-
ies according to the physician. The following
serves as a basic guideline only.

Tray or Mayo stand, suture removal set, ster-
ile towel, sterile gloves, drapes (as needed),
dressings (as indicated), sterile basin, sterile
gauze, antiseptic solution, tape, infectious- FIGURE 20-42 A sample suture removal tray
waste bag, sharps container, patient gown if setup.
needed, patient’s chart, pen or pencil
CAUTION: Do not leave the tray unat-
Procedure tended.
10. Put the infectious-waste bag, tape, and
1. Assemble required equipment. sterile gloves near the tray.
2. Wash hands. 11. Introduce yourself. Identify the patient.
3. Check the dates and sterilization indi- Explain the procedure. Obtain the
cators on all sterile supplies to make patient’s consent.
sure the supplies are still sterile. Make 12. If necessary, ask the patient to remove
sure that the package has not been wet clothing and put on a patient gown.
and that there are no tears or openings Position and drape according to loca-
on the wrap. tion of sutures. Reassure the patient as
4. Place a sterile towel on the tray. needed.
NOTE: Follow the correct procedure for 13. Assist the physician as necessary during
unwrapping and placing all supplies. the procedure.
Refer to Chapter 14:8. NOTE: Frequently, medical assistants
5. Place a sterile basin on the tray. Put are trained and authorized to remove
gauze and antiseptic solution in the sutures.
basin. 14. When the sutures have been removed,
6. Place dressings on the tray. Outer dress- place a clean dressing and bandages on
ings should be on the bottom. This way, the wound. Use dressing forceps or wear
dressings are in order of use. sterile gloves to apply a sterile dressing
to the site (figure 20-43A). Then apply
7. Place the sterile suture removal set on roller gauze and/or tape to anchor the
the tray. dressing in place (figure 20-43B).
8. Place a sterile towel or needed drapes 15. Instruct the patient on wound care and
on the tray. provide written instructions if this is
9. Check the tray to be sure all equipment office policy. Watch closely for signs of
is present (figure 20-42). distress. If no signs of weakness or dizzi-
ness are noted, help the patient get off
the table.
756 CHAPTER 20
PROCEDURE 20:5B
16. Wear gloves to clean and sterilize all
instruments. If the suture set is dispos-
able, place it in a sharps container. Put
all contaminated disposable supplies in
the infectious-waste bag. Use a disin-
fectant to wipe any contaminated
areas.
example, date, time, sutures removed
FIGURE 20-43A Use dressing forceps or from right forearm, sterile dressing
wear sterile gloves to apply a sterile dressing to applied, and your signature and title.
the site. The physician sometimes records the
required information.
Practice
evaluation sheet for 20:5B, Assisting
with Suture Removal, to practice

FIGURE 20-43B Anchor the dressing in listed on the evaluation sheet, your
place with roller gauze and/or tape. instructor will grade your performance.
20:6 INFORMATION moves through the atria, causing the muscles of

the atria to contract. The impulse next travels to
Recording and Mounting an the atrioventricular (AV) node, through a band of
fibers called the bundle of His, and then through
Electrocardiogram the right and left bundle branches to the final
In order to understand an electrocardio- branches, called the Purkinje fibers. The Purkinje
gram (ECG), it is essential to understand fibers distribute the impulse to the muscles of the
the electrical conduction pattern in the muscles right and left ventricles, which then contract. The
of the heart (figure 20-44). The contraction of the movement of the electrical impulse is recorded
heart muscles is controlled by electrical impulses by an electrocardiograph machine as a series of
within the heart. The electrical impulse originates waves known as a PQRST complex. The P wave
in the sinoatrial (SA) node of the heart, located occurs as the impulse originates in the SA node
near the top of the right atrium. The impulse and travels through the atria. The QRS wave rep-
30216_20_Ch20_715-778.indd 756 1/16/08 1:46:53 PM

Q wave is a negative deflection or wave.
R wave is a positive deflection or wave.
S wave is a negative wave.
T wave is a positive wave and represents

ventricular repolarization.
U wave (occasionally seen in some patients)

is a positive deflection and associated with
repolarization.
Sinoatrial
(SA) node
Atrioventricular
(AV) node Bundle of His
(AV) Bundle Right and left

bundle branches
Purkinje fibers
Atrial Ventricle
depolarization repolarization Cycle
V begins
(contraction systole) (relaxation diastole)
O again
L T
P U P
T
T
A P
G U-wave
Q occurs in
E
S some patients
Ventricle
depolarization
(contraction systole)
TIME
FIGURE 20-44 As the electrical impulse passes through the conduction pathway in the heart, it creates a
pattern recorded as an electrocardiogram.
resents the movement of the impulse through the an ECG. Each PQRST pattern represents the
AV node, bundle of His, bundle branches, and electrical activity that occurs during each con-
Purkinje fibers. The T wave represents the repo- traction of the heart muscle; thus, each PQRST
larization of the ventricles, or the period of recov- complex represents one heartbeat. Because an
ery in the ventricles before another contraction abnormal pattern of the electrical impulses will
occurs. be evident on an ECG, the ECG can be used to
The pattern of electrical current in the heart diagnose disease and/or damage to the muscles
is recorded by an electrocardiograph machine as of the heart.
758 CHAPTER 20
Using special electrodes, the electrical activ- Lead 2 (II) connects the right arm and the left
ity is recorded from different angles, called leads. leg.
The different leads give the physician a more
complete picture of the heart. By noting an elec- Lead 3 (III) connects the left arm and the left
trical disturbance in any of the leads, the physi- leg.
cian can determine which parts of the heart are ♦ Augmented voltage leads: Include aVR, aVL,
diseased or malfunctioning. and aVF. They are different angles of the stan-
A complete ECG normally consists of 12 leads. dard leads 1 (I), 2 (II), and 3 (III). The aVR
Electrodes are placed at specific locations on the stands for augmented voltage right arm, aVL
body to pick up the voltage present. Connections stands for augmented voltage left arm, and
between the various electrodes create the various aVF stands for augmented voltage left foot.
leads. The leads are labeled as 1 (I), 2 (II), 3 (III), ♦ Chest leads: The six chest, or precordial, leads
aVR, aVL, aVF, V1, V2, V3, V4, V5, and V6. There are record angles of the electrical impulse from a
three classifications: standard, augmented, and central point within the heart to specific sites
chest leads (figure 20-45). on the front of the chest (refer to figure 20-46).
♦ Standard, or limb, leads: Include leads 1 (I), 2 Chest electrodes are placed at six specific loca-
(II), and 3 (III) (figure 20-46). Each records the tions on the chest to obtain these angles (refer
voltage between two extremities. back to figure 20-45).
Lead 1 (I) connects the right arm and the left V1: fourth intercostal (between ribs) space on
arm. the right side of the sternum (breastbone)
Lead Arrangement and Coding
Standard limb leads
Standard
or bipolar Sensors Marking
limb leads connected code
Lead 1 LA & RA . RA LA
Lead 2 LL & RA ..
Lead 3 LL & LA ...
Augmented limb leads
Augmented
unipolar RL LL
limb leads
aVR RA & (LA-LL) -
aVL LA & (RA-LL) --
aVF LL (RA-LA) ---
Chest leads
Chest or V1 – .
precordial V2 – ..
leads V3 – ...
1 2
V C & (LA-RA-LL) V4 – ... . 3 4 5 6
V5 – ... ..
V6 – ... ...
V1 Fourth intercostal V3 Midway between V5 At horizontal level of

space at right position V2 and position V4 at left
margin of sternum position V4 anterior axillary line
V2 Fourth intercostal V4 Fifth intercostal space V6 At horizontal level of
space at left at junction of left position V4 at left
margin of sternum midclavicular line midaxillary line
FIGURE 20-45 The lead arrangement and coding for a standard electrocardiogram.
30216_20_Ch20_715-778.indd 758 1/16/08 1:47:04 PM

(A) Standard limb or bipolar leads
Electrodes Connected
Lead I LA and RA
Lead II* LL and RA
Lead III LL and LA Lead I Lead II Lead III

* Also used for rhythm strip
(B) Augmented limb leads
aVR RA and (LA-LL)
aVL LA and (RA-LL)
aVF LL and (RA-LA) Lead aVR Lead aVL Lead aVF
(C) Precordial or chest leads Electrodes connected Placement
V1 V1 and (LA-RA-LL) Fourth intercostal space at right margin of sternum

V2 V2 and (LA-RA-LL) Fourth intercostal space at left margin of sternum
V4 V4 and (LA-RA-LL) Fifth intercostal space at junction of left
midclavicular line
V3 V3 and (LA-RA-LL) Midway between position 2 and position 4
V5 V5 and (LA-RA-LL) At horizontal level of position 4 at left anterior
axillary line
V6 V6 and (LA-RA-LL) At horizontal level of position 4 at left midaxillary
line
V6
V1 V2 V3
V5 V4 V5 V6
V1 V2 V3 V4
Precordial leads
FIGURE 20-46 Lead types, connections, and placement. (A) Standard limb leads. (B) Augmented voltage
(AV) leads. (C) Precordial or chest leads.
V2: fourth intercostal space on the left side of V5: same level as 4 but at left anterior axillary
the sternum line
V3: midway between the V2 and V4 positions V6: same level as 4 but at left midaxillary line
V4: fifth intercostal space at the junction of the
midclavicular line (line drawn from the mid- Electrodes are placed on various parts of the
dle of the clavicle) body to record these 12 leads. The electrodes are
760 CHAPTER 20
coded so that each is put in the proper place.

Codes are as follows:
♦ RA for right arm: Placed on the fleshy outer
area of the upper part of the right arm
♦ LA for left arm: Placed on the fleshy outer area
of the upper part of the left arm
♦ RL for right leg: Placed on the fleshy part of
the lower right leg; does not record a lead but
serves as a ground for electrical interference
♦ LL for left leg: Placed on the fleshy part of the
lower left leg
♦ C or V for chest: Placed at six different loca-
tions on the chest (refer to figure 20-45)
The ECG paper is marked with a code so that
the physician knows which lead is being recorded.
Some machines record this code automatically,
but others must be coded manually. The code for
each lead is as follows: FIGURE 20-47 A multiple-channel electrocardio-
graph produces a full sheet of paper showing all 12
. Lead 1 (I) —. V1 leads. (Courtesy of Spacelabs Medical, Inc.)
. . Lead 2 (II) —.. V2
. . . Lead 3 (III) —.. . V3 move 10 millimeters on the graph (10 small
– aVR —.. .. V4 squares or 2 large squares on the paper) (fig-
– – aVL —.. .. . V5 ure 20-48). If the standard is not the correct
– – – aVF —.. .. .. V6 height during the standard check, the ST’D
Most newer ECG machines print the name of the must be adjusted. Follow the manufacturer’s
lead (I, II, AVR, etc.) on the paper instead of using instructions to adjust the standard to the
the codes. proper height.
Electrocardiograph machines vary slightly, ♦ Stylus heat control: Used to adjust stylus tem-
but most have the same basic parts. It is impor- perature (figure 20-49). The heat from the sty-
tant to read the specific manufacturer’s instruc- lus melts the plastic coating on the ECG paper,
tions with each machine. There are two main forming the black line. At the same time, the
classes of electrocardiographs: single channel coating lubricates the stylus. If the tracing is
and multiple channel. The single-channel elec- too light, the heat must be increased. If the
trocardiograph produces a narrow strip of paper tracing is too dark, the heat must be decreased.
showing one lead at a time. The multiple-channel Follow manufacturer’s instructions to adjust
electrocardiograph produces a full sheet of paper the heat.
showing all 12 leads (figure 20-47). All electrocar-
diograph machines have most of the following
basic parts:
♦ Main switch: Turns the machine on and off.
♦ Pilot light: A red light that indicates that
the machine is on. On newer, computer-
ized machines, this may be indicated by a
Ready signal on the computer readout.
♦ ST’D (standard control): Used to perform a
quality-control check and to ensure that the
Correct Too high Too low
machine is calibrated correctly to record elec-
trical impulses. One millivolt electrical input FIGURE 20-48 Standardization: correct, too high,
should cause the stylus (recording needle) to too low.
25mm/SEC Chart Speed
Light Ideal
Stylus Heat Control

SPEED 25 enganges the paper drive to
Increases or decreases heat in the tip of the run at an internationally-accepted stan-
stylus making the recording darker or lighter. dard of 25 mm per second. This is the
“normal” speed for recording.
FIGURE 20-49 Stylus heat control: light and
ideal. 50mm/SEC Chart Speed
♦ Stylus position control: Used to move the

recording up and down on the paper. In most
cases, this control should be adjusted to cen-
ter the ECG on the paper.
♦ Record, or speed, control: Has three or four
separate functions to control the amplifier
and paper drive, or the speed.
(1) Amp off: The unit remains inactive; used SPEED 50 doubles the speed of the paper
when changing chest lead positions. to 50 mm per second. Useful when heart
rate is rapid or when certain segments of a
(2) Amp on: The amplifier is activated, caus- complex are close together, since it extends
ing the stylus to move, but the paper the recording to twice its normal width.
remains stationary. This position is useful FIGURE 20-50 Speed settings for an electrocar-
for chest leads. After the chest electrode is diogram.
in position, turn the machine to amp on,
allow the stylus to stabilize or settle, and
turn to Run 25. channel ECG machines print the name of the
(3) Run 25: The position normally used when lead on the paper instead of the code.
recording an ECG. The paper moves at a ♦ Lead selector switch: Allows selection of the
rate of 25 millimeters per second (figure lead to be run. It has a position for checking
20-50). the standard and other positions for running
(4) Run 50: The position used when the com- each of the 12 leads of a standard ECG. This
plexes of the ECG are so close together switch is not necessary on a multiple-channel
that they are difficult to examine. It ECG because all 12 leads are run at the same
increases the speed of the paper to 50 mil- time.
limeters per second, stretching the ECG ♦ Sensitivity switch: Controls amplification (fig-
out on the paper. Often used for extremely ure 20-51). It is usually set at position 1. In
fast tachycardias (pulse rate above 100). To position 1, the standard is ten small blocks or
make the physician aware of the increased two large blocks high. Other positions are as
speed, “Run 50” must be written on the follows:
paper with a pen or pencil (if not recorded (1) Position 2: Increases the size of the com-
automatically by the machine). plex, making it twice as large. The stan-
♦ Lead coding marker: Places a mark or code on dard will then be 20 small blocks or 4 large
the paper to identify the lead being recorded. blocks high. Used when the PQRST pat-
On most electrocardiograph machines, this is tern is too small to be easily seen.
done automatically. On some machines, the (2) Position 1/2: Decreases the size of the
lead mark is recorded manually at the start of complex to one-half its normal size. The
each lead recording. Many of the multiple- standard will then be five small blocks or
762 CHAPTER 20
one large block high. Used when the

Sensitivity Control PQRST pattern is too large.
Regulates the "gain" or output of the amplifier. Many patients are frightened or apprehen-
Normal position is 1. Height of small complexes
sive about having an ECG taken. It is impor-
can be doubled—or height of large complexes
halved—by switching to 2 or 1/2, respectively. tant to explain this procedure to the patient.
Stress that it is not a painful or uncomfortable
test. Position the patient comfortably with all
body parts supported. Encourage the patient to
relax and to avoid moving while the ECG is being
taken. Muscle movement can cause electrical
interference and will be displayed on the ECG
recording. Nervous tension can also interfere
with the recording.
After all the ECG leads have been recorded, a
1 section of each recorded lead is mounted. Most
newer multiple-channel machines produce com-
plete mounts. These mounts are sometimes
attached to firmer backings using self-stick tape.
For ECGs from single-channel machines, many
different types of mounts are used. Some contain
slots for inserting the individual leads. Some con-
tain tape or self-stick areas for placement of each
of the leads. Others utilize clamps. The final
1/2
mount should be neat, with each lead in the cor-
rect area on the mount. The mount should be
labeled with the patient’s name and address, doc-
tor’s name, date, and any other pertinent infor-
mation.

the assignment sheet for 20:6, Recording and
Mounting and Electrocardiogram. Then return
and continue with the procedure.
2
FIGURE 20-51 Sensitivity control on an electro-

cardiogram.
PROCEDURE 20:6
Recording and Equipment and Supplies
Mounting an Electrocardiograph machine, electrodes and
straps, chest electrode and chest strap (if
Electrocardiogram used), electrocardiograph cables and cords,
NOTE: This procedure provides basic examination gown, drape, gel or electro pads,
information about recording and gauze pads and/or tongue depressors, pen or
mounting an electrocardiogram (ECG). pencil
It is important to read the specific oper-
ating instructions provided with each
electrocardiograph machine.
PROCEDURE 20:6
Procedure trodes are placed on fleshy parts of the
lower legs. Avoid bony areas. Different
1. Assemble required equipment. types of electrodes may be used. Follow
the directions provided with the elec-
2. Wash hands. trode. General guidelines are as follows:
3. Introduce yourself. Identify the patient. a. Electrodes and straps (figure 20-52A):
Explain the procedure. Reassure the Connect the electrode strap to the
patient. Tell the patient that you will be ears of the electrode. Put gel or an
recording the activity of the heart. Stress electrolyte pad on the electrode to
that the patient will not feel any discom- increase conduction. Use the end of
fort from the procedure. Explain that the electrode to gently scrape the
the patient must lie perfectly still skin at the area of application. Posi-
because muscle movement will inter- tion the electrode and bring the strap
fere with the recording. around the arm or leg until it holds
4. Ask the patient to remove clothing and the electrode snugly against the skin.
put on an examination gown. The gown Avoid stretching the strap too tightly.
is usually open in the front for easy b. Disposable electrodes (figure 20-
placement of the chest electrodes. 52B): Use a tongue depressor or
NOTE: In some offices, the patient is gauze pad to vigorously rub the site
asked to remove clothing from the waist to stimulate circulation. If the
up and to uncover the lower legs. patient’s skin is oily, wipe the elec-
trode area with alcohol and allow it
5. Position the patient. Patient should be
to air-dry. Then, separate the elec-
lying on a firm bed or examination table.
trode from the protective backing to
A small pillow can be placed under the
uncover the sticky surface. Apply the
head. Use the drape to cover the
electrode to the correct site using a
patient.
smooth, even motion to make sure
6. Position the machine in a convenient all parts of the electrode adhere to
location. It may be easier to work from the skin. The disposable electrodes
the left side because this is where most can only be used with ECG machines
of the chest leads are positioned. that have an alligator clip attached to
7. Connect the power cord to the machine.
Do not let the power cord pass under
the bed or examination table. Plug it in
so that it is pointing away from the
patient.
CAUTION: Check the three prongs and
the cord before using the power cord.
Never use a defective cord for any pro-
cedure.
NOTE: Positioning the power cord away
from the patient helps reduce electrical
interference.
8. Apply the four limb electrodes. The arm FIGURE 20-52A A limb electrode is posi-
electrodes are placed on the fleshy outer tioned on the fleshy outer part of the arm or leg
areas of the upper arms. The leg elec- and held in place with a limb strap.
764 CHAPTER 20
PROCEDURE 20:6
NOTE: Alligator clip attachments can be
purchased for older ECG cable wires.
9. Apply the chest electrodes. Refer to fig-
ure 20-45 for the exact location for each
electrode. Different types of electrodes
may be used. Follow the directions pro-
vided with the electrode. General guide-
lines include:
a. Suction bulb electrodes: These are
small rubber bulbs each with a suc-
tion cup (figure 20-52D). Electrolyte
gel is squeezed into the suction cup.
The rubber bulb is depressed to cre-
ate a suction effect when the cup is
placed on the proper position on the
chest. If one electrode is used, it is
moved from position to position as
the ECG chest leads are run. If six
FIGURE 20-52B A disposable electrode has electrodes are used, each is placed in
a sticky surface that allows the electrode to position before the chest leads are
adhere to the skin. (Courtesy of Spacelabs run. The chest strap is not used with
Medical, Inc.) this type of electrode.
b. Disposable electrodes: Use a tongue
the ends of the cable wires (figure 20- depressor or gauze pad to vigorously
52C). rub the site to stimulate circulation.
NOTE: If the skin surface is hairy, it may If the patient’s skin is oily, wipe the
be necessary to shave small areas at the electrode area with alcohol and allow
application sites to allow for better
attachment and conduction of the elec-
trodes.
FIGURE 20-52C An alligator clip on the end FIGURE 20-52D A suction bulb electrode is
of the electrocardiograph cable wire attaches to squeezed as it is applied, creating suction to
the disposable electrode. hold the electrode in place.
PROCEDURE 20:6
it to air-dry. Then, separate the elec- LL, and brown or multicolored for chest
trode from its protective backing to or V depending on the model of the ECG
uncover the sticky surface. Apply the machine.
electrode to the site using a smooth,
11. Turn on the main switch.
even motion to make sure all parts of
the electrode adhere to the skin. Posi- 12. Check standardization of the machine.
tion all six chest electrodes in the Put the lead selector in the ST’D posi-
correct locations. tion. Set the record switch to Run 25.
Make sure sensitivity is set at 1. Center
NOTE: If the skin surface is very hairy, it
the stylus. Momentarily press the ST’D
may be necessary to shave small areas
button. Check the standard. It should be
at the application sites to allow for bet-
10 small blocks or 2 large blocks high.
ter attachment and conduction of the
electrodes. NOTE: If the standard is not correct,
adjust it to the correct height by follow-
10. Connect the cable wires to the elec-
ing manufacturer’s instructions.
trodes. The lead wires should follow
body contour (figure 20-53). If there is 13. Check the color of the line. It should be
excess wire, coil it in a loop and fasten clearly visible but not too dark. Adjust
with tape or a band. Pay particular atten- the stylus heat control, if necessary.
tion to the labels and color codes to NOTE: Remember, the stylus heat melts
connect the cable ends to the correct the coating on the paper to form the line.
electrodes. Make sure all connections
are tight and in the same direction. 14. Record the leads. Set sensitivity at 1. Put
the record switch at Run 25. Record sev-
NOTE: Labels are as follows: RA for right eral complexes. Insert a standard mark
arm; LA for left arm; RL for right leg; LL between the complexes, if required. In
for left leg; and C or V for chest. some agencies, a standard mark is
NOTE: Color codes are as follows: white placed at the beginning of the ECG. In
for RA, black for LA, green for RL, red for other agencies, a standard mark is cen-
tered in each lead of the ECG. Follow
agency policy.
NOTE: The standard mark should not
be on any part of the complex. It should
be on the base line between complexes,
or after the T wave of one ECG cycle and
before the P wave of the next ECG cycle.
Repeat the process until a correct stan-
dard is present.
15. On a computerized electrocardiograph,
set the control to Auto and run the 12-
lead ECG. When all 12 leads are com-
plete, proceed to step 19 of this
procedure. On a manual electrocardio-
graph, set the lead selector switch to
each lead and allow the machine to
FIGURE 20-53 The lead cables should follow record an adequate amount for each
body contour when they are connected to the lead. While running the leads, make sure
electrodes. the following points are noted:
766 CHAPTER 20
PROCEDURE 20:6
a. The recording should be centered on 17. Turn the record switch to Amp off. Place
the paper. the chest electrode at the V2 position.
b. Record a sufficient amount for each Twist the electrode slightly while apply-
lead. Leads 1, 2, and 3 each usually ing. Set the selector switch at V2. Turn
require 8–10 inches. Each of the the machine to Amp on. Allow the stylus
remaining leads usually require 5–6 to settle. Center the stylus. Switch to
inches. Run 25. Run lead V2.
c. An ST’D mark is in the center of each NOTE: If six suction bulb or disposable
lead. Some agencies and physicians electrodes are in place for the chest
prefer an ST’D mark at the start of leads, the leads can be run without stop-
each lead. Others prefer ST’D marks ping the machine. Simply move the lead
on the first limb lead and the first selector switch to the next chest lead
chest lead. Follow agency or physi- position.
cian preference. 18. Repeat step 17 for the remaining four
d. Make sure that the amplitude of the chest leads (V3, V4, V5, and V6).
complexes is correct. If complexes 19. When all 12 leads have been run, turn
are too small, set sensitivity to 2. If the lead selector to the standard posi-
complexes are too large, set sensitiv- tion. Allow all of the recording to run out
ity to 1⁄2. If the sensitivity is changed, of the machine. Then turn the record
be sure to insert a standard in the switch to Off.
lead. A standard that is five small
blocks or one large block high indi- NOTE: Make sure that all of the record-
cates a sensitivity setting of 1⁄2. A ing is out of the machine’s window
standard that is 20 small blocks or 4 before stopping the movement of the
large blocks high indicates a sensitiv- machine.
ity setting of 2. 20. Turn the power button off. Remove the
e. Make sure complexes are not too electrodes from the patient. Use warm
close together. For severe tachycar- water to wash the patient’s skin. Dry the
dias, it is often necessary to increase skin thoroughly. Help the patient get off
the speed to Run 50. Alert the physi- the examination table or bed.
cian by marking “Run 50” on the 21. Discard all disposable electrodes. Wash
paper with pen or pencil. suction bulb electrodes thoroughly and
f. Make sure that no electrical interfer- disinfect, if necessary. Use cleanser to
ence or artifact is present. Watch clean metal electrodes thoroughly. Rinse
patient movement. Use a ground each electrode well. Dry and replace in
wire, as needed. the proper container.
16. Run leads 1, 2, 3, aVR, aVL, aVF, and V1 as NOTE: The metal electrodes should be
instructed in steps 14 and 15. There is cleaned until they are bright and shiny,
no need to turn off the machine between because dirty or corroded electrodes are
leads. Simply move the lead selector poor electricity conductors.
switch to the next position.
22. Clean straps as needed. Coil all wires
NOTE: Some machines code each lead and replace in the proper box. Coil
automatically; others require manual power cord and replace in the proper
coding when leads are run; and newer box.
machines record the name of the lead
instead of the code.
PROCEDURE 20:6
NOTE: If wires are bent, they will break. mounts, and to make sure that the
length for each lead is cut correctly. Look
23. Write the patient’s name, the date, and
for the lead marking code to determine
the doctor’s name on the ECG. If the
the lead represented. Use scissors or an
ECG has been recorded with all 12 leads
ECG cutter to cut a section of the lead to
on one sheet of paper, it may be neces-
the correct length. Attach the lead to the
sary to attach it to a self-stick mount.
correct area of the mount. Make sure
Follow manufacturer’s instructions. This
you match the lead markings on the
type of ECG is sometimes simply placed
ECG strip with those on the mount to
in the patient’s chart without mounting.
place each section in its correct location
If the ECG is one long roll, cut into leads
(figure 20-54). Most mounts have adhe-
and attach to a mount. It is important to
sive backs for easy attachment. When all
follow instructions provided with the
PATIENT Charles Williams NO. DATE 11–1–2001

SEX AGE HEIGHT WEIGHT B/P POSITION
DRUGS RATE:ATRIAL VENT. AXIS
INTERVAL: PR QRS QT RHYTHM
INTERPRETATION
INTERPRETED BY Dr. T. Winston Lewis

LEAD I LEAD II LEAD III
AVR AVL AVF
aVR aVL aVF
V1 V2 V3
V1 V2 V3
V4 V5 V6
V4 V5 V6
FIGURE 20-54 A mounted single-channel electrocardiogram.

768 CHAPTER 20
PROCEDURE 20:6
12 leads are mounted in their correct
areas, recheck the ECG. Make sure it is
neat and labeled correctly.
NOTE: Some physicians prefer to read
Practice
the strip before it is mounted to mark evaluation sheet for 20:6,
specific areas or arrhythmias to mount. Recording and Mounting an
24. Wash hands. Electrocardiogram, to practice this
patient’s chart or the agency form; for have mastered this skill, sign the
example, date, time, ECG recorded, and sheet and give it to your instructor
your signature and title. for further action.

alphabetical listing of products by brand name

20:7 INFORMATION or generic (chemical) name. All drugs listed by
generic name are followed by a list of brand
Using the Physicians’ Desk names. The manufacturer’s name is given in
Reference (PDR) parentheses after each product. In addition, if
The Physicians’ Desk Reference, or PDR, is a drug information is found in a later section,
book that provides essential information about the page number for the information is pro-
drugs and medications currently in use. It is pub- vided.
lished yearly and has periodic supplements that ♦ Product classification, or category, index: The
provide up-to-date information on new products third main section is blue. It is a quick-
available. The Physician’s Desk Reference for Non- reference section for drugs available for various
prescription Drugs is another resource that can conditions. For example, if a patient has an
be used to obtain information about over-the- infection, a physician can readily find a long list
counter (OTC) medications that can be purchased of drugs that can be used to treat the condition
without a prescription. by looking under the heading antibiotics. Drugs
The PDR contains six main sections. Each in each group are listed by brand names, with
section has a specific purpose and provides cer- the manufacturers in parentheses. If additional
tain types of information. The main sections are information on the drug is provided in a later
as follows: section, the page number is listed.
♦ Manufacturers’ index: This is the initial white ♦ Product identification guide: The next main
section. Major drug manufacturers in the section provides color, actual-size pictures of
United States are listed in alphabetical order. a variety of drugs. Drugs shown are listed
Company names, addresses, telephone num- alphabetically by manufacturers. Identifica-
bers, and departments to contact are listed. A tion numbers may be given for some drugs,
partial list of each manufacturer’s products is but these numbers may be changed by the
also included. manufacturer.
♦ Brand and generic names: The second main ♦ Product information: This is the largest sec-
section, this is usually pink. It provides an tion in the book and is white. It contains a
detailed list of drugs and information on the

chemical nature, indications for use, contra-
indications, warnings, adverse reactions, rec-
ommended dosage, and administration routes
for each drug. Drugs are listed by manufactur-
ers. All page number references in preceding
sections refer to this section.
♦ Diagnostic product information section: This
green section lists all diagnostic products,
such as radiographic (X-ray) dyes, by manu-
facturers.
Several smaller information sections can be
found in the back of the PDR. These include:
♦ Poison control centers: a list of certified poison
control centers arranged alphabetically by
state
♦ Discontinued products: an alphabetical listing
of products withdrawn from the market dur-
ing the past year
♦ U.S. Food and Drug Administration (FDA) tele-
phone directory: the numbers for key report-
ing programs and information services
♦ Key to FDA Use-in-Pregnancy ratings: describes
how drugs are rated for use during pregnancy
It is important to check the PDR for informa-
tion regarding actions, dosages, side effects, and FIGURE 20-55 Check the Physicians’ Desk
other vital facts for any medication (figure 20-55). Reference for information regarding actions, dos-
You must be familiar with this reference and be ages, side effects, and other vital facts for any
able to use it readily. In addition, other references medication.
available for pharmaceutical product informa-
tion should be available for use. Examples of STUDENT: Read Procedure 20:7, Using the
these include the National Formulary, the Phar- Physicians’ Desk Reference (PDR). Then go to the
macopoeia of the United States of America (USP), workbook and complete the three assignment
and packet inserts that are found in medication sheets for 20:7, Using the Physicians’ Desk Refer-
packages. ence (PDR).
PROCEDURE 20:7
PDR while you are reading this section.
Using the PDR Become familiar with each section and
what it contains.
Equipment and Supplies 2. Think of the name of a major drug man-
Physicians’ Desk Reference, pen or pencil ufacturer. Turn to the manufacturers’
index and find this name. Note the
Procedure address of the company, the telephone
number, and the department to con-
1. Read Information section 20:7 on the tact.
PDR. Locate the various sections in the
770 CHAPTER 20
PROCEDURE 20:7
3. Think of the common brand name of a which you do not know the name. After
drug with which you are familiar. Turn finding a drug that looks interesting,
to the brand and generic name index look up the name in the brand and
(pink section) and locate this drug. If it generic name index, where an alphabet-
refers to a page number, turn to that ical list is provided. This list provides a
page in the product information section page number in the product informa-
and read the information provided on tion section, where more information
the drug. about the drug can be obtained. Turn to
the correct page and read the product
4. Think of the generic, or chemical, name
information provided.
of a drug. You may want to look in jour-
nals for some examples. Locate the 7. Go to the workbook and complete the
name of this drug in the brand and first assignment sheet for 20:7, Using
generic name index. If a list of brand the Physicians’ Desk Reference (PDR).
names appears, choose one or two of Use Information section 20:7 and the
the names. Refer to the noted page steps in this procedure to complete the
number in the product information sec- assignment sheet. When you are done,
tion to read about the properties of give the assignment sheet to your
these drugs. Note how they are alike and instructor.
how they might differ.
8. Your instructor will grade assignment
5. Think of any type of illness or disease. sheet 1. Note any changes or correc-
Find this disease in the blue product tions. Then complete assignment sheet
classification, or category, index. Note 2. Give this sheet to your instructor for
the list of drugs available to treat the grading. Note any changes or correc-
condition. Look up product information tions on assignment sheet 2 before com-
on several of the drugs listed. pleting assignment sheet 3.
6. Glance through the product identifica-
tion guide. Note the pictures of the many Final Checkpoint After reviewing your
drugs listed. Pay particular attention to completed assignment sheets for 20:7,
size, manufacturers’ marks such as Using the Physicians’ Desk Reference
numbers or letters, and coloring. These (PDR), your instructor will grade your
signs might help you identify a drug for performance.
20:8 INFORMATION
♦ Liquids:
Working with Math (1) Aqueous suspension: medication is dis-
and Medications solved in water
(2) Suspension: solid form of a medication is
A medication is a drug used to treat or pre-
mixed with solution; usually must be
vent a disease or condition. The following
shaken well before use to resuspend the
discussion provides only basic information about
medication in the solution
the preparation and administration of medica-
(3) Syrup: concentrated solution of sugar,
tions. Even so, it should make you aware of the
water, and medication
need for extreme care in handling all medica-
(4) Tincture: medication dissolved in alcohol
tions. It is important to remember that only
authorized persons can administer medications. NOTE: Liquid medications must be poured
Medications are available in various forms, at eye level to ensure that the dosage is exact
usually liquids, solids, or semi-solids. (figure 20-56).
cocoa butter is often the base material;

usually inserted into the rectum, vagina,
or urethra
Medications may be given in a variety of ways.
Some of the routes of administration are:
♦ Oral: given by mouth; for liquid and solid
forms
♦ Rectal: given in the rectum; liquids and sup-
positories
♦ Injections: given with a needle and syringe;
often called “parenteral,” which means any
FIGURE 20-56 Liquid medications must be
route other than the alimentary canal (diges-
poured at eye level to ensure the dosage is correct.
tive tract) (figure 20-58).
(1) Subcutaneous (SC or SQ): injected into
the layer of tissue just under the skin
(2) Intramuscular (IM): injected into a muscle
(3) Intravenous (IV): injected into a vein
(4) Intradermal: injected just under the top
layer of skin; the skin tests for allergies and
tuberculosis (TB) are examples
Caplet ♦ Topical or local: applied directly to the top of the
Capsule
skin; ointments, sprays, liquids, and adhesive
patches; transdermal adhesive patches applied
to the skin can be used to provide a continuous
Tablet dosage of medication for motion sickness, heart
disease, hormonal imbalance, and nicotine
withdrawal (for individuals who are trying to
stop smoking) (figure 20-59A and B)
FIGURE 20-57 Types of solid medications.
♦ Inhalation: inhaled, or breathed in, by way of
sprays, inhalers, or special machines
♦ Solids (figure 20-57):
(1) Capsule: gelatin-like shell with medica- ♦ Sublingual: given under the tongue
tion inside There are six main points to watch each and
(2) Pill: powdered medication mixed with a every time a medication is given. These can be
cohesive substance and molded into called the “six rights.”
shape ♦ Right medication
(3) Tablet: compressed or molded prepara-
tion ♦ Right dose, or amount
(4) Troche or lozenge: large, flat disc that is ♦ Right patient
dissolved in the mouth ♦ Right time
(5) Enteric coated: medication with a special
coating that does not dissolve until the ♦ Right method or mode of administration
substance reaches the small intestine ♦ Right documentation
♦ Semi-solids: Certain safety rules must be observed when
(1) Ointment: medication in a fatty base giving medication.
(2) Paste: ointment with an adhesive sub- ♦ Read the order carefully. Note all six rights.
stance
(3) Cream: medication with water-soluble ♦ Check for patient allergies before administer-
base ing any medication.
(4) Suppository: medication mixed with sub- ♦ Check the label three times to be sure it is the
stances that melt at body temperature; correct medication (figure 20-60). The label
772 CHAPTER 20
Intramuscular Subcutaneous Intravenous Intradermal
90-degree 45-degree 25-degree 10- to 15-

angle angle angle degree angle
Epidermis
Dermis
Subcutaneous
tissue
Muscle
Intramuscular Subcutaneous Intravenous Intradermal

(IM) (SC) (IV) (ID)
Angle of Injection for Parenteral Administration of Medications

FIGURE 20-58 Types of injections and the correct angles for administration of parental medications.
Backing layer
Drug reservoir
Microporous
rate-limiting
membrane
Adhesive
formulation
Skin Image not available due to copyright restrictions
surface
Blood
vessel
FIGURE 20-59A The layers of a transdermal

patch allow the medication to be absorbed into the
bloodstream over a period of time, frequently 24
hours.
♦ Never administer a medication you did not
personally prepare.
♦ Know the action of the drug, the usual dosage,
the route of administration, and the side
must be read when the bottle is taken from the effects.
shelf, as the medication is poured, and when ♦ Store medications in a safe, cool, dry area. Make
the bottle is replaced on the shelf. sure they are out of the reach of children.
♦ Prepare or administer medication only on the ♦ Check expiration dates on all medications.
order of a physician. Medications must never be used beyond the
Use the PDR or the literature that comes with

each medication to learn the basic information
about the medication. Question dosages or uses
that do not seem correct.

the assignment sheet for 20:8, Working with Math
and Medications.
20:8A INFORMATION
Using Roman Numerals
Roman numerals are used for some drugs
and solutions. In addition, they are some-
times used when ordering supplies. The follow-
ing chart shows Arabic numerals and their Roman
numeral equivalents.
FIGURE 20-60 Check the label of any medication Arabic Roman Arabic Roman
at least three times. 1 I 10 X
2 II 20 XX
3 III 30 XXX
expiration date and must be destroyed. Follow 4 IV 40 XL
agency policy and federal and state laws to 5 V 50 L
dispose of medications. If the policies/laws 6 VI 100 C
call for destruction of the medications, it is 7 VII 500 D
best to flush them down the toilet to destroy 8 VIII 1,000 M
them. Record all required information regard- 9 IX
ing the destruction of the medication accord- The key numerals are I, V, X, L, C, D, and
ing to agency policy. Controlled substances, M. Any number can be formed by using these
such as narcotics, must be returned to the numerals.
pharmacy as required by law. Make sure you Usually, no more than three of any one Roman
complete all required documentation when numeral is used to represent a number. For exam-
you return expired controlled substances to ple, III represents the number 3. An I is placed
the pharmacy. If a partial amount of a unit before the V to form the Roman numeral IV to
dose (single dose package) of a controlled represent the number 4. Thus, IV is used in place
substance is used because of the dosage of IIII for the number 4.
ordered, witnesses must cosign when the If the numeral for a smaller number is used
remaining medication is destroyed. after the numeral for a larger number, all of the
♦ Never use medication from an unmarked bot- numbers are added together. See the following
tle. Make sure the label is clear. If in doubt, examples:
throw it out.
♦ VII 5 1 1 7
♦ Do not return medication to a bottle. This can ♦ LXX 50 10 10 70
lead to serious errors. Discard any medication
that is not used. If the numeral for a smaller number is used in
♦ Report all mistakes immediately. front of the numeral for a larger number, the
smaller number is subtracted from the larger
♦ Concentrate while handling any medication. number. See the following examples:
Avoid distractions.
♦ IX 1 before 10 10 1 9
♦ Use paper and pencil to calculate dosages.
Avoid “mental” math because it can cause ♦ XC 10 before 100 100 10 90
errors. ♦ CD 100 before 500 500 100 400
774 CHAPTER 20
STUDENT: Go to the workbook and complete NOTE: The same order is used for meters and
the assignment sheet for 20:8A, Using Roman liters. The word meter or liter is simply used in
Numerals. place of the word gram in the previous example.
Metric measurements are easy to convert from
20:8B INFORMATION unit to unit because the units represent multiples
of 10. Placement of a number in relation to the
Converting Metric decimal point represents the powers of 10, so met-
ric measurements can be converted by moving the
Measurements decimal point according to the power of 10
The metric system is used in many health required. Note the following examples:
care fields. There are three basic units of
measurement in the metric system:
♦ How many grams (g) are in 40 kilograms (kg)?
First, list the measurements in order from
♦ gram: measures mass or weight largest to smallest:
♦ liter: measures volume or liquid kg hg dkg g dg cg mg
♦ meter: measures length or distance To go from kilograms (kg) to grams (g), move-
The metric system is based on the power of ment is three places to the right. The decimal
10. Units other than the basic units are created by point should therefore be moved three places
either multiplying or dividing the basic units of to the right.
measurement by the correct power of 10. The Write 40 as 40.000 and then move the decimal
other units and the powers of 10 that they repre- point:
sent are as follows:
4 0 .0 0 0 40000.0
♦ kilo (k): thousands, or 103, or 1,000 (multiply 艛↑艛↑艛↑
the base unit by 1,000) The answer is that 40 kilograms (kg) equal
40,000 grams (g).
♦ hecto (h): hundreds, or 102, or 100 (multiply
the base unit by 100) ♦ How many dekaliters (dkL) are in 14,500 mil-
liliters (mL)?
♦ deka (dk): tens, or 101, or 10 (multiply the base
unit by 10) First, list the measurements in order from
largest to smallest:
♦ base unit of measurement (gram, liter, meter):
ones, or 100 kL bL dkL L dL cL mL
♦ deci (d): tenths, or 10–1, or 0.1 (divide the base To go from milliliters (mL) to dekaliters (dkL),
unit by 10) move four places to the left. The decimal point
♦ centi (c): hundredths, or 10–2, or 0.01 (divide should therefore be moved four places to the
the base unit by 100) left.
Write 14,500 as 14,500.0 and then move the
♦ milli (m): thousandths, or 10–3, or 0.001 (divide
decimal point:
the base unit by 1,000)
1 4 5 0 0 . 0 1.45000
As an example, if the gram (g) is used as the 艛↑艛↑艛↑艛
↑
base unit of measurement, other units are formed The answer is that 14,500 milliliters (mL) equal
as follows: 1.45 dekaliters (dkL).
♦ kilogram (kg): 1 kg 1,000 g As can be seen from the previous examples,
the first step in converting metric measurements
♦ hectogram (hg): 1 hg 100 g
is to list the units in order from largest to small-
♦ dekagram (dkg): 1 dkg 10 g est, using the prefixes along with the base unit of
♦ grams (g): base unit of measurement, measurement. If movement is from left to right,
so 1 g 1 g the decimal point is moved the same number of
♦ decigram (dg): 1 dg 0.1 g places to the right. If movement is from right to
left, the decimal point is moved the same num-
♦ centigram (cg): 1 cg 0.01 g ber of places to the left. This principle can also be
♦ milligram (mg): 1 mg 0.001 g expressed as follows:
♦ To move from a larger unit of measurement in ♦ Units for measuring volume or liquid:
the metric system to a smaller unit of mea- 1 drop (gtt) 0.0667 milliliter (mL) or cubic
surement, move the decimal point the correct centimeters (cc)
number of places to the right. 15 drops (gtts) 1 milliliter (mL) or cubic cen-
NOTE: Each unit change moves the decimal timeter (cc)
point one place to the right. 1 teaspoon (tsp) 5 milliliters (mL) or cubic
centimeters (cc)
♦ To move from a smaller unit of measurement 1 tablespoon (tbsp) 15 milliliters (mL) or
in the metric system to a larger unit of mea- cubic centimeters (cc)
surement, move the decimal point the correct 1 ounce (oz) 30 milliliters (mL) or cubic
number of places to the left. centimeters (cc)
NOTE: Each unit change moves the decimal 1 pint (pt) 500 milliliters (mL) or cubic cen-
point one place to the left. timeters (cc)
There is also interrelationship between units 1 quart (qt) 1,000 milliliters (mL) or cubic
in the metric system. One important example is centimeters (cc), or 1 liter (L)
that a cube that measures 1 centimeter on all NOTE: Remember, 1 milliliter (mL) equals 1 cubic
sides will hold 1 milliliter of water. So, 1 cubic centimeter (cc). Milliliters are used much more
centimeter holds 1 milliliter. Therefore, cubic frequently than cubic centimeters in health
centimeters and milliliters are sometimes inter- care.
changed. It is important to remember that 1 cubic To convert household measurements to met-
centimeter (cc) is the same as 1 milliliter (mL), or ric measurements, multiply the amount of the
that 1 cc is equal to 1 mL. household measurement by the number of met-
ric units equal to one of the household units.
STUDENT: Go to the workbook and complete Rule to remember: When converting from
the assignment sheet for 20:8B, Converting Metric household (English) to metric, multiply.
Measurements.
Formula:
20:8C INFORMATION English measurement conversion unit
metric measurement
Converting Household (English)
Examples:
Measurements
♦ How many milliliters (mL) are in 3 ounces?
The household, or English, system of mea-
There are 30 mL in 1 oz.
surement is the common system used in the
Multiply 3 30 90
United States, but the metric system is used in
There are 90 milliliters (mL) in 3 ounces.
many health care fields. Therefore, it is some-
times necessary to convert from the household ♦ How many milliliters (mL) are in 5 teaspoons?
system to the metric system. There are 5 mL in 1 tsp.
The household system of measurement uses Multiply 5 5 25
many different units of measurement. The metric There are 25 mL in 5 tsp.
conversions for the most common household ♦ How many milliliters (mL) are in 3 pints?
units of measurement are: There are 500 mL in 1 pt.
♦ Units for measuring mass or weight: Multiply 500 3 1,500 mL
1 ounce (oz) 0.028 kilogram (kg), or 28 There are 1,500 mL in 3 pt.
grams (g) ♦ How many kilograms are in 120 pounds?
1 pound (lb) 0.454 kilogram (kg), or 454 There are 0.454 kg in 1 lb.
grams (g) Multiply 0.454 120 54.48 kg
♦ Units for measuring length or distance: There are 54.48 kg in 120 lb.
1 inch (in) 0.025 meter (m) ♦ How many meters are in 12 feet?
1 foot (ft) 0.31 meter (m) There are 0.31 m in 1 ft.
1 yard (yd) 0.91 meter (m) Multiply 0.31 12 3.72 m
1 mile 1,601.6 meters (m) There are 3.72 m in 12 ft.
776 CHAPTER 20
To convert metric measurements to house- ♦ How many pints (pt) are in 1,250 milliliters?
hold measurements, divide the amount of the There are 500 mL in 1 pt.
metric measurement by the number of metric Divide 1,250 ÷ 500 2.5
units equal to one of the household units. There are 2.5 pt in 1,250 mL.
Rule to remember: When converting from
metric to household, divide.
♦ How many ounces (oz) are there in 1.232 kilo-
grams?
Formula: There are 0.028 kg in 1 oz.
Metric measurement ÷ conversion unit Divide 1.232 ÷ 0.028 44
English measurement There are 44 oz in 1.232 kg.
Examples: ♦ How many feet (ft) are in 62 meters (m)?
♦ How many ounces (oz) are in 300 milliliters There are 0.31 m in 1 ft.
(mL)? Divide 62 ÷ 0.31 200
There are 30 mL in 1 oz. There are 200 ft in 62 m.
Divide 300 ÷ 30 10
There are 10 oz in 300 mL. STUDENT: Go to the workbook and complete
the assignment sheet for 20:8C, Converting House-
♦ How many teaspoons (tsp) are in 20 milliliters hold (English) Measurements.
(mL)?
There are 5 mL in 1 tsp.
Divide 20 ÷ 5 4 teaspoons
There are 4 tsp in 20 mL.

Scorpions and snakes to cure cancer?
Twenty thousand people each year experience development of a glioma, a cancerous
brain tumor. Gliomas grow at a rapid rate and can kill a person in a matter of weeks. In most
cases, surgical removal of the tumors will destroy too much brain tissue, therefore, treat-
ment is extremely limited. Few patients live more than 6–8 months after the tumor is diag-
nosed.
Now there is hope for people with gliomas. Dr. Harald Sontheimer is working with a
research team at the University of Alabama at Birmingham. He discovered that a giant Israeli
golden scorpion secretes a venom that is safe to humans but paralyzes muscles of a cock-
roach. The toxic molecules of the venom target a specific protein on the muscles of the cock-
roach, killing the cockroach. Through research, Sontheimer found that the same protein is
present on the cancerous glioma cells. When the venom seeks out the tumor cells, it kills the
cells and stops the growth of the glioma without harming the healthy cells in the brain. Cur-
rently, clinical trials are being conducted on more than 60 people with gliomas. If the trials
are successful, the U.S. Food and Drug Administration (FDA) may approve this venom-
derived drug as an accepted form of treatment.
Many other researchers are working with snake venom. They are trying to use snake
venom to destroy the blood vessels that supply cancerous tumors with nourishment and
fluid. If access to nourishment is restricted, tumors will not be able to grow. Another group
of researchers is trying to use the venom from bees to kill malignant cells and destroy can-
cerous tumors. One of the leading causes of death will be eliminated if research finds that
readily available venom from scorpions, snakes, and bees can cure a cancerous tumor.
3. Electrocardiogram: research electrocardio-

CHAPTER 20 SUMMARY graphs, myocardial infarctions, and cardiac
arrhythmias
A basic knowledge of the main skills used by 4. Medications: research the Physician’s Desk
medical assistants is beneficial for many health Reference, other medication references, pre-
care workers, because many of these skills are scription medications, and sites of drug
used in other health care areas. manufactures
Height and weight measurements are im-
5. Suppliers: research medical and pharmaceuti-
portant in evaluating basic health status of pa-
cal suppliers to evaluate the types of supplies
tients. Thus, knowing how to correctly measure
and equipment available for medical offices;
height and weight is important for every health
compare and contrast different types of ECG
care worker.
machines; locate online pharmacies to deter-
Proper positioning of patients for examina-
mine services available
tions and other procedures is another skill need-
ed by the medical assistant. By following correct
techniques, the medical assistant can properly
prepare patients, as well as provide patients with
comfort and privacy. REVIEW QUESTIONS
A knowledge of the basic instruments used
and procedures performed during physical ex-
aminations, minor surgery, and suture removal 1. Why are height and weight measurements
is essential. This knowledge allows the medical important?
assistant to work with the physician to provide 2. Identify at least six (6) different positions that
quality health care to the patient in an efficient can be used for examinations and/or treat-
manner. Understanding the basic principles of ments. For each position, list at least two (2)
electrocardiography allows the medical assistant types of treatments or examinations that are
to efficiently perform an electrocardiogram. performed when a patient is in the position.
A knowledge of how to find information on
3. Differentiate between a Snellen chart, Jaeger
medications and of correct mathematical calcu-
card, and an Ishihara plate by stating the type
lation techniques is also an important responsi-
of eye defects evaluated with each method.
bility of the medical assistant. By mastering these
basic skills, the medical assistant can become an 4. Interpret or define each of the following:
important part of the medical office team. a. OU
b. OS
c. OD
INTERNET SEARCHES d. myopia
e. hyperopia
5. Name the areas of the body examined and the
type of tests performed during each of the
following examinations:
1. Organizations: find Web sites for the American a. ear, eye, nose, and throat
Medical Association, American Association of b. gynecological
Medical Assistants, American Society of c. general physical
Podiatric Assistants, Registered Medical
6. Explain at least five (5) standard precautions
Assistants of the American Medical Technolo-
that must be observed while assisting with
gists, and the American Optometric Associa-
minor surgery and/or suture removal.
tion to research medical assisting careers and
duties 7. Name the twelve (12) leads for an electrocar-
diogram and the code that is used for each
2. Vision: search for information on Snellen
lead.
charts, Ishihara color plates, Jaeger system,
myopia, hyperopia, and ophthalmic and 8. List the six (6) rights that must be observed
optometric treatments and care while administering any medication.
778 CHAPTER 20
9. Interpret or convert each of the following For additional information on medical assist-
measurements: ing careers, contact the following associations:
a. XXIV
♦ American Association of Medical Assistants
b. MMCMXCIII
20 North Wacker Drive, Suite 1575
c. 300 mL oz
d. 5 lb kg
Internet address: www.aama-ntl.org
e. 1,750 mL pt
f. 6 tsp mL ♦ Registered Medical Assistants of the American
g. 5 ft m Medical Technologists
710 Higgins Road
10. Use a Physician’s Desk Reference to find the Park Ridge, IL 60068
medication Celebrex. List the main action of Internet address: www.amt1.org
this drug, suggested dosage, route of adminis-
tration, and warnings/side effects.
CHAPTER 21 Nurse Assistant
Skills
Chapter Objectives
Observe Standard ◆ Admit, transfer, or discharge a patient,
Precautions demonstrating proper care of patient’s
belongings
◆ Position a patient in correct alignment and
Instructor at This Point with no bony prominences exposed
◆ Move and turn a patient in bed, using correct
body mechanics
Safety—Proceed with ◆ Perform the following transfer techniques
Caution (using correct body mechanics): dangling,
wheelchair, chair, and stretcher
◆ Transfer a patient by way of a mechanical lift
on Federal Law and observe all safety points
◆ Make closed, open, and occupied beds, using
correct body mechanics
Math Skill ◆ Administer routine, denture, and special oral
hygiene
◆ Administer hair care and nail care
◆ Administer a backrub, using the five major
movements
Science Skill ◆ Shave a patient, using a safety or an electric
razor, and observe all safety precautions
◆ Change a patient’s bedclothes
Career Information ◆ Administer a partial bed bath and a complete
bed bath with perineal care
◆ Help a patient take a tub bath or shower,
observing all safety points
◆ Measure and record intake and output
Technology
780 CHAPTER 21
◆ Assist a patient with eating; feed a patient

◆ Administer a bedpan or urinal
◆ Provide catheter care
◆ Empty a urinary-drainage unit without contaminating the catheter or unit
◆ Provide ostomy care
◆ Collect urine and stool specimens
◆ Administer tap-water, soap-solution, disposable, and oil-retention enemas
◆ Insert a rectal tube
◆ Apply restraints, observing all safety precautions
◆ Administer preoperative care as directed
◆ Shave an operative site, observing all safety precautions
◆ Prepare a postoperative unit with all equipment in correct position
◆ Apply surgical (elastic) hose
◆ Apply binders
◆ Safely administer oxygen with an oxygen mask, nasal cannula, or tent
◆ Give postmortem care
KEY TERMS
alignment (ah-line⬘-ment) impaction postoperative care
anesthesia (an-es-thee⬘-sha) intake and output (I&O) preoperative care
bed cradle mechanical lifts pressure (decubitus) ulcer
binders micturate (mick⬘-chur-rate⬙) (deh-ku⬘-beh-tuss uhl⬙-sir)
catheter midstream (clean catch) rectal tube
closed bed specimen restraints
colostomy mitered corners stoma
complete bed bath (CBB) (my⬘-terd corn⬙-urz) stool specimen
contracture Montgomery straps suppository
(kon-track⬘-tyour⬙) occult blood (ah-kult⬘) (sup-poz⬘-ih-tor-ee)
dangling occupied bed surgical (elastic) hose
defecate (deaf ’-eh-kate⬙) open bed surgical shave
dehydration operative care 24-hour urine specimen
(dee⬙-high-dray⬘-shun) oral hygiene ureterostomy
edema (eh-dee⬘-mah) ostomy urinary-drainage unit
enema partial bed bath urinate
fanfolding personal hygiene urine specimen
ileostomy postmortem care void
Nurse Assistant Skills 781
CAREER HIGHLIGHTS
Nurse assistants, also called nurse aides, nurse technicians, patient care technicians (PCTs),
and orderlies, work under the supervision of registered nurses or licensed practical nurses.
They are important members of the health care team. Educational requirements vary with
states, but many assistants obtain training through health science technology education
(HSTE) programs. Assistants who work in long-term care facilities or home health must
complete a minimum of 75 to 120 hours in a mandatory state-approved program and pass a
written and/or competency examination to obtain certification or registration. Additional
educational requirements include continuing education, periodic evaluation of perfor-
mance, and retraining if the assistant is not employed for two or more years.
Geriatric aides or assistants provide care for patients in environments such as extended
care facilities, nursing homes, retirement or assisted-living centers, and adult day care
agencies.
Home health assistants or aides perform many of the duties of nurse assistants, but they
provide care in the patient’s home, usually for an extended period of time. Examples of
patients requiring home care include patients who have just been discharged from a hospi-
tal or long-term care facility, patients with a disability, elderly patients who require assis-
tance, and patients receiving hospice care. In addition to performing many of the personal
care duties of the nurse assistant, home health assistants may also shop for food and pre-
pare meals, maintain and clean the home environment, wash laundry, and accompany
patients shopping or to medical appointments. Throughout this chapter, special notes are
provided to help a home health assistant adapt the procedure to home care.
The duties of nurse assistants vary depending on the facility in which they work and on
the nursing practice laws of the state in which they work. Every nurse assistant must
know and follow the legal requirements of the state in which he or she is employed. In addi-
tion to the knowledge and skills presented in this chapter, nurse assistants must also learn
and master skills such as:
◆ Presenting a professional ◆ Learning medical ◆ Positioning patients for
appearance and attitude terminology and assisting with
◆ Obtaining knowledge ◆ Observing all safety
examinations and
regarding health care precautions treatments
delivery systems, ◆ Administering basic
◆ Practicing all principles of
organizational structure, infection control physical therapy including
and teamwork range-of-motion
◆ Taking and recording vital exercises, ambulation
signs with assistive devices, and
responsibilities
◆ Administering first aid warm or cold applications
◆ Communicating
and cardiopulmonary ◆ Performing basic
effectively resuscitation laboratory tests such as
◆ Being sensitive to and monitoring glucose or
◆ Promoting good nutrition
respecting cultural and a healthy lifestyle to testing urine with reagent
diversity maintain health strips
◆ Comprehending anatomy, ◆ Utilizing computer skills
◆ Measuring and recording
physiology, and height and weight ◆ Recording information on
pathophysiology
patient records
782 CHAPTER 21
21:1 INFORMATION A personal inventory list is made of clothing,

valuables, and personal items to protect a
Admitting, Transferring, and patient’s possessions. In a hospital, a family
member frequently will take clothing home. Any
Discharging Patients clothing or personal items (such as radios) kept
As a health care worker in a hospital or long- in the room should be noted on the list. The list
term care facility, one of your responsibili- should be checked and signed by both the health
ties may be to admit, transfer, and discharge care worker and the patient (or the person respon-
patients or residents. Although these procedures sible for the patient). At the time of transfer or
vary slightly in different facilities, basic principles discharge, the personal inventory list of clothing
apply in all facilities. and personal items should be checked to make
Admission to a health care facility can cause sure that the patient has all belongings.
anxiety and fear in many patients and their If the family does not take valuables home,
families. Even a transfer from one room or unit in these should be put in a safe place. Most facilities
a facility to another room or unit can cause anxi- require that they be kept in a safe. A description
ety, because the individual has to adjust to of the valuables is usually written on a valuables
another new environment. It is essential for the envelope, and the items are placed inside. If
health care worker to create a positive first money is left in the patient’s wallet, it should be
impression. By being courteous, supportive, and counted, and the exact amount recorded on the
kind, the health care worker can do much to alle- envelope. Both the health care worker and the
viate fear and anxiety. Giving clear instructions patient (or the person responsible for the patient)
on how to operate equipment and on the type of should check the items and sign the valuables
routine to expect, such as mealtimes, helps the envelope. The valuables are then put in the safe,
patient or resident become familiar with the envi- and a receipt is given to the patient or put on the
ronment. It is also important not to rush while patient’s chart. If a patient is transferred or dis-
admitting, transferring, or discharging a patient. charged, the valuables are taken from the safe
Allow the individual to ask questions and to and checked by both the health care worker and
express concerns. If you do not know the answers the patient. Again, both individuals sign the enve-
to specific questions, refer these questions to lope to indicate that valuables have been returned
your immediate supervisor. to the patient.
Most facilities have specific forms that are Patients and family members should be ori-
used during an admission, transfer, or dis- ented to the facility. Instructions on how to
charge. A sample admission form is shown in fig- operate the call signal, bed controls, television
ure 21-1. The forms list the procedures that must remote control (if present), telephone, and other
be performed and will vary slightly from facility similar equipment should be provided. Visiting
to facility. It is important for the health care hours, location of lounges, smoking regulations,
worker to become familiar with the information availability of services such as religious services
required on such forms. Much of the information and activities, mealtimes, and other rules or rou-
on an admission form is used as a basis for the tines in the facility should be explained. Many
nursing care plan. Therefore, this information facilities give patients and family members pam-
must be complete and accurate. If the patient is phlets or papers listing such information, but it is
unable to answer the questions, a relative or the still important to explain the main information.
person responsible for the patient is usually able Transfers are done for a variety of reasons. A
to provide the information. In some facilities, transfer is sometimes related to a change in the
questions regarding medications and allergies patient’s condition. For example, a person may
are the responsibility of the nurse. Follow agency be transferred from or to an intensive care unit.
policy regarding these sections on the form. Other times, a transfer is made at the patient’s
When a patient is admitted to a facility, cer- request, such as a request to be moved to a pri-
tain procedures are performed. These usually vate room. Agency policy must be followed dur-
include vital signs, height and weight measure- ing any transfer. The reason for the transfer
ments, and collection of a routine urine speci- should be explained to the patient and family.
men. Follow correct techniques while performing This is usually the responsibility of the doctor or
these procedures. nurse. The new room or unit must be ready to
PATIENT PREFERS TO BE ADDRESSED AS: MODE OF TRANSPORTATION:

❑ Ambulatory ❑ Other Smoker: Y ❑ N ❑
❑ Wheelchair
FROM: ❑ E.R. ❑ E.C.F. ❑ Home ❑ M.D.'s Office ❑ Stretcher
COMMUNICATES IN ENGLISH: ❑ Well ❑ Minimal ❑ Not At All ❑ Other Language (Specify)

❑ INTERPRETER (Name Person) ❑ None Home Telephone No. ( )
Work Telephone No. ( )
ORIENTATION TO ENVIRONMENT: PERSONAL BELONGINGS: (Check and Describe)
❑ Armband Checked ❑ Call Light ❑ Clothing

❑ Bed Control ❑ Phone
❑ Jewelry
❑ ❑ Money
❑ TV Control Side Rail Policy
❑
❑ Walker
❑ Bathroom Visitation Policy
❑ Wheelchair
❑ Personal Property Policy ❑ Smoking Policy
❑ Cane
❑ Other
DENTURES: CONTACT LENSES: GLASSES: ❑ Y ❑N HEARING AID: ❑ Y ❑N

❑ Upper ❑ Partial ❑ Hard ❑ LT ❑ RT PROSTHESIS: ❑ Y ❑N
❑ Lower ❑ None ❑ Soft
(Describe)
DISPOSITION OF VALUABLES: IN CASE OF EMERGENCY NOTIFY:

❑ Patient Given To: Name:
❑ Home
Relationship: Relationship:
❑ Placed in
Safe Home Telephone No. ( )
(Claim No.) Work Telephone No. ( )
VITAL SIGNS: ALLERGIES:

TEMP: ❑ Oral ❑ Rectal ❑ Axillary Medications: ❑ None Known Food: ❑ None Known
❑ ❑ Tape
PULSE: ❑ Radial ❑ Apical Respiratory Penicillin
❑ Other (List) (Shellfish, Eggs, Milk, etc.)
Rate ❑ Sulfa
❑ RT ❑ Iodine
B/P: ❑ LT ❑ Standing ❑ Sitting ❑ Lying ❑ Aspirin
HEIGHT: WEIGHT: ❑ Bedside ❑ Morphine
❑ Standing ❑ Demerol
(Prescription/
MEDICATIONS: Non-Prescription) Dose/Frequency Last Dose (Date/Time) DISPOSITION OF MEDICATIONS:
1. ❑ None Brought to Hospital
2. ❑ Sent Home
3. With
4. ❑ To Pharmacy: (List)
5.
6.
ADMITTING DIAGNOSIS:
NURSE'S SIGNATURE: RN/LVN Date Time
FIGURE 21-1 A sample admission form.

784 CHAPTER 21
receive the patient. Clothing, personal items, and packed. A careful check of the unit, including any
certain equipment must be transferred with the drawers, closets, and storage areas, helps ensure
patient. The health care worker should also find that all items are found. Most facilities require
out how to transport the patient. Wheelchairs, that a staff member accompany the individual to
stretchers, and even the patient’s bed can be used a car. Some facilities allow patients to walk, but
for the transfer. An organized and efficient trans- many prefer to transport patients by wheelchair.
fer helps prevent fear and anxiety in the patient. If a patient is to be transferred by ambulance, the
A physician’s order is usually required before ambulance attendants will bring a stretcher to
a patient or resident can be discharged from a the room. In this case, it is important for the
facility. If an individual plans to leave the facility health care worker to have the patient’s belong-
without permission, report this immediately to ings ready for the transport. Again, most agencies
your supervisor. Facilities have special policies have forms or checklists that are used during dis-
that must be followed when a person leaves charge to ensure that all procedures are fol-
against medical advice (AMA). When an order for lowed.
discharge has been received, the health care
worker must check and pack the patient’s belong- STUDENT: Go to the workbook and complete
ings. The personal inventory list completed at the the assignment sheet for 21:1, Admitting, Transfer-
time of admission must be checked to ascertain ring, and Discharging Patients. Then return and
that all of the patient’s belongings have been continue with the procedures.
PROCEDURE 21:1A
Admitting the Patient
Admission form and/or personal inventory
list, valuables envelope, admission kit (if
used), thermometer, stethoscope, sphygmo-
manometer, watch with second hand, scale,
urine-specimen container, patient gown (if
needed), paper, pen or pencil
Procedure FIGURE 21-2 A sample admission kit.

(Courtesy of Medline Industries, Mundelein, IL)
1. Obtain orders from your immediate
supervisor or check orders to obtain
permission for the procedure. side stand. Check the room to be sure all
equipment and supplies are in their
2. Wash hands.
proper places.
3. Assemble equipment. Prepare the room
4. You may be required to go to the admis-
for the admission. Fanfold the top bed
sions office to get the new patient or
linen down to open the bed. If an admis-
resident, or the patient may be brought
sion kit is used, unpack the kit and place
to the room by other personnel.
the items in the bedside stand or table.
The admission kit usually includes a 5. Greet and identify the patient. Ask the
water pitcher, cup, soap dish, bar of patient if he or she prefers to be called
soap, lotion, and mouthwash (figure by a particular name. Introduce yourself
21-2). Place a bedpan and/or urinal, by name and title to the patient and to
bath basin, and emesis basin in the bed- any family members present. If another
PROCEDURE 21:1A
patient is in the room, introduce the NOTE: Observe the patient carefully
new patient. during the admission process. Record
all observations noted. If the patient
NOTE: Be friendly and courteous at all
expresses certain concerns, be sure to
times. Do not rush or hurry the patient.
record and report these concerns.
6. Ask the family or visitors to wait in the
10. Measure and record vital signs. Follow
lounge or lobby while you complete
the procedures outlined in Chapter 15.
the admission process, if this is facility
policy. 11. Weigh and measure the patient. Follow
Procedure 20:1A. Record the informa-
NOTE: If a patient is not able to answer
tion on the admission form.
questions, a family member or other
person responsible for the patient can 12. Complete a personal inventory list. Be
remain in the room to complete the sure to list all personal items that will be
admission process. kept in the patient’s unit such as cloth-
ing, shoes, clocks, radios, religious
7. Close the door and screen the unit (fig-
items, and books. Make sure the patient
ure 21-3). Ask the patient to change into
or a responsible individual checks and
a gown or pajamas. Assist the patient as
signs the list. Assist the patient as neces-
necessary.
sary in hanging up clothing or putting
NOTE: In long-term care facilities, resi- away personal items.
dents usually wear street clothes during
13. Complete a valuables list. If a family
the day. In this case, gowns or pajamas
member takes the valuables home, be
are not used.
sure to obtain a signature on the proper
8. Position the patient comfortably in the form. If the valuables are to be placed in
bed or in a chair. a safe, fill out the form and obtain the
9. Complete the admission form. Ask ques- patient’s and/or a relative’s signature.
tions slowly and clearly. Provide time for Follow agency policy for placing the
the patient to answer the questions. valuables in the safe.
14. Obtain a routine urine specimen if
ordered. Follow Procedure 21:10A.
15. Orient the patient to the facility by dem-
onstrating or explaining the following:
a. Call signal or light
b. Bed controls
c. Television remote control and/or
television rental policy
d. Telephone
e. Bathroom facilities and special call
signal in bathroom
f. Visiting hours
g. Mealtimes and menu selections
FIGURE 21-3 Close the door and screen the h. Activities or services available
unit to provide privacy while the patient
undresses. i. Health care facility regulations
786 CHAPTER 21
PROCEDURE 21:1A
NOTE: Many health care facilities pro- 21. Record all required information on the
vide pamphlets or printed forms with patient’s chart or the agency form; for
the required information. However, is example, date; time; admission form
still important to explain the main infor- complete, valuables placed in safe,
mation to the patient and/or family. patient tolerated procedure well; and
16. Fill the water pitcher, if the patient is
abnormal observations to your immedi-
allowed to have liquids.
ate supervisor.
17. Observe all checkpoints before leaving
the patient. Make sure the patient is
comfortable and in good body align-
ment; the siderails are up, if indicated;
the bed is at its lowest level; the call sig- Practice
nal and supplies are in easy reach; and Go to the workbook and use the
the area is neat and clean. evaluation sheet for 21:1A,
Admitting the Patient, to practice
19. Wash hands. you have mastered this skill, sign
20. When the admission process is com- the sheet and give it to your
plete, allow family members to return to instructor for further action.
the unit. Answer any questions they may
have regarding facility policies. If you do
not know answers to their questions, Final Checkpoint Using the criteria
obtain the correct answers from your listed on the evaluation sheet, your
immediate supervisor. instructor will grade your performance.
PROCEDURE 21:1B
immediate supervisor to check. Check
Transferring the the method of transport to be used and
Patient obtain a wheelchair or stretcher, or use
the patient’s bed.
Equipment and Supplies 2. Assemble equipment.
Transfer checklist (if used), personal inven- 3. Knock on the door and pause before
tory list, valuables list, cart (if needed), wheel- entering. Introduce yourself. Identify
chair or stretcher, paper, pen or pencil the patient. Explain the procedure to
the patient.
Procedure NOTE: Reassure the patient as neces-
sary. Patients are often apprehensive.
1. Obtain permission from your immedi-
ate supervisor or check orders to obtain 4. Wash hands.
permission for the procedure. Find out 5. Collect the patient’s clothing and per-
the new unit or room number. Check to sonal items. Check all items against the
be sure that the unit is ready or ask your admission personal inventory list to be
PROCEDURE 21:1B
sure all items are present. Put the items
in a bag or place them on a cart for
transport. If the patient wears dentures
and/or a hearing aid, make sure he or
she has these items.
6. Put any bedside equipment to be trans-
ferred on a cart. This may include items
such as the water pitcher, cup, soap
dish, soap, emesis basin, bedpan, and
bath basin. Check whether special
equipment is to be transferred. Follow
agency policy regarding transfer of
equipment.
7. If valuables are to be transferred, they
must be checked and signed for by both
the patient and the health care worker.
The valuables are usually kept in the
facility safe, and the room or unit num-
ber of the patient is changed on the
valuables bag.
8. Assist the patient into a wheelchair or
stretcher. Follow the appropriate proce-
dure as outlined in Information section
21:2.
9. Transport the patient and the cart of
supplies to the new unit or room (figure FIGURE 21-4 The patient is usually trans-
21-4). If help is not available, the patient ferred in a wheelchair to the new room or unit.
may be taken to the new room first and
the belongings taken afterward.
needed. Be sure to obtain correct signa-
CAUTION: Observe all safety precau- tures according to agency policy.
tions while transporting the patient.
12. Help put away the patient’s clothing and
10. Introduce the patient to the new staff personal items.
members. Assist the staff members in
getting the patient positioned comfort-
ably in bed or in a chair. If another
patient is in the room, introduce the
ment, the siderails are up (if indicated),
patient. Orient the patient to the new
the bed is at its lowest level, the call sig-
room or unit by explaining or demon-
nal and supplies are in easy reach, and
strating the use of the equipment and
the area is neat and clean.
supplies.
NOTE: The staff members of the new
unit may orient the patient. 15. Wash hands.
11. Check the patient’s belongings with the 16. Complete the transfer checklist. Record
new staff member. Use the personal all required information on the patient’s
inventory and/or valuables checklist as chart or the agency form; for example,
788 CHAPTER 21
PROCEDURE 21:1B
date; time; transferred to room 239-A by
wheelchair, patient tolerated procedure
well, transfer checklist complete; and
your signature and title. Practice
17. Return to the patient’s previous room. evaluation sheet for 21:1B,
Strip the bed and remove any equip- Transferring the Patient, to practice
ment that was not transferred. Follow
agency policy for cleaning the room.
NOTE: This may be the responsibility of the sheet and give it to your
the housekeeping department. If so, instructor for further action.
notify housekeeping that the patient
has been transferred.
18. Wash hands.
19. Report to your immediate supervisor listed on the evaluation sheet, your
that the transfer has been completed. instructor will grade your performance.
PROCEDURE 21:1C
3. Knock on the door and pause before
Discharging the entering. Introduce yourself. Identify
Patient the patient. Explain the procedure.
4. Wash hands.
Equipment and Supplies 5. Close the door and screen the unit. Help
Discharge checklist (if used), personal inven- the patient dress, if assistance is
tory list, valuables list, wheelchair (if needed), needed.
cart (if needed), paper, pen or pencil
6. Assemble all of the patient’s personal
belongings. If the patient wears den-
Procedure tures and/or a hearing aid, make sure he
or she has these items. Check drawers,
1. Obtain orders from your immediate closets, the bedside stand or table, and
supervisor or check orders to obtain storage areas. Check all items against
permission for the procedure. Check the personal inventory list to be sure
with the patient to determine when rel- everything is present. Obtain the
atives or other individuals will be there patient’s signature according to agency
to discharge patient. policy.
NOTE: If the patient is to be discharged 7. Assemble any equipment that is to be
to another facility by ambulance, deter- given to the patient. Examples include
mine the time the ambulance will the supplies in the admission kit, such
arrive. as the pitcher and cup.
PROCEDURE 21:1C
8. Check to make sure that the patient has CAUTION: Observe all safety factors
received final instructions from the while transporting the patient.
nurse and/or physician. These may
15. Help put the patient’s belongings in the
include discharge instructions and pre-
car.
scriptions.
16. Say good-bye to the patient.
9. Obtain the patient’s valuables, if they
are in a safe. Check the valuables with 17. Return to the unit. Strip the bed and
the patient. Obtain the correct signature remove any equipment in the unit. Fol-
to indicate that the valuables were low agency policy for cleaning the unit.
returned to the patient. Replace equipment.
NOTE: In some agencies, the patient or NOTE: In some facilities, this is the
a responsible person obtains the valu- responsibility of the housekeeping
ables directly from the safe. In such a department. If so, notify housekeeping
case, tell the patient how to obtain the that the patient has been discharged.
valuables. 18. Wash hands.
10. Complete a discharge checklist, if one is 19. Record all required information on the
used, to be sure all procedures are com- patient’s chart or the agency form; for
plete. example, date; time; patient discharged,
11. Place all of the patient’s belongings on a taken to husband’s car by wheelchair,
cart, if needed. Packed items sometimes tolerated procedure well; and your sig-
are taken to the car by a relative. nature and title. Report to your immedi-
ate supervisor that the discharge has
12. Assist the patient into a wheelchair. Fol-
been completed.
low Procedure 21:2F.
NOTE: Most facilities require the use of
wheelchairs to transport patients. Some
facilities allow patients to walk, but
health care workers must accompany
patients. Follow agency policy.
Practice
13. In some facilities, the patient must go to Go to the workbook and use the
the business office if financial arrange- evaluation sheet for 21:1C,
ments are not complete. Check with Discharging the Patient, to practice
your immediate supervisor or check the this procedure. When you believe
discharge slip to determine whether the you have mastered this skill, sign
patient must stop at the business office. the sheet and give it to your
If this is necessary, transport the patient instructor for further action.
to the business office.
14. Transport the patient to the exit area.
Help the patient into the car.
NOTE: If a cart is used to transfer the Final Checkpoint Using the criteria
patient’s belongings, another staff mem- listed on the evaluation sheet, your
ber should take the cart to the car. instructor will grade your performance.
790 CHAPTER 21
skin. The discoloration does not disappear

21:2 INFORMATION after pressure has been relieved. In stage II
(figure 21-5B), abrasions, bruises, and/or open
Positioning, Turning, Moving, sores develop as a result of tissue damage to
and Transferring Patients the top layers of the skin (epidermis and der-
As a health care worker, you may be respon- mis). In stage III (figure 21-5C), a deep open
sible for positioning, turning, moving, and crater forms when all layers of the skin are
transferring many patients. If these procedures destroyed. Fat and muscle tissues are exposed.
are done correctly, you will provide the patient In stage IV (figure 21-5D), damage extends
with optimum comfort and care. In addition, you into muscle, tendon, and bone tissue. It is
will prevent injury to yourself and the patient. easier to prevent pressure ulcers than it is to
It is essential to remember that improper treat them. In addition, if pressure ulcers are
moving, turning, or transferring of a patient detected in early stages, immediate treatment
can result in serious injuries to the patient. Some can help prevent further damage. Effective
patients cannot be moved safely without special ways to prevent pressure ulcers include pro-
assistance or mechanical devices. If a patient has viding good skin care; using moisturizing
restrictions for moving or transferring, the restric- lotions on dry skin; prompt cleaning of urine
tions should be posted outside the door. If you and feces from the skin; massaging in a circu-
are not sure whether a patient can be moved or
transferred safely, always ask your supervisor
before attempting any procedure. Remember,
you are legally responsible for the safety and well-
being of the patient.
Correct body mechanics are required for all
procedures discussed here. Review and
practice all of the rules of correct body mechan- Image not available due to copyright restrictions
ics as outlined in Information Section 13:1. If you
are unable to move or turn a patient by yourself,
always get help.
ALIGNMENT
Patient care must be directed toward maintain-
ing normal body alignment. Alignment is
defined as positioning body parts in relation to
each other to maintain correct body posture.
Benefits of proper alignment include:
♦ Prevent fatigue: Correct alignment helps the
patient feel more comfortable and prevents
fatigue.
♦ Prevent pressure ulcers: A pressure
ulcer, also called a decubitus ulcer,
Image not available due to copyright restrictions
pressure sore, or bedsore, is caused by pro-
longed pressure on an area of the body that
interferes with circulation. Pressure ulcers are
common in areas where bones are close to the
skin, such as the tailbone, or coccygeal area;
hips; knees; ankles; heels; and elbows. The tis-
sue breakdown of a pressure ulcer occurs in
four stages. In stage I (figure 21-5A), a red or
blue–gray discoloration appears on the intact
FIGURE 21-6A An alternating air pressure

mattress constantly changes the pressure points
against a patient’s skin. (Courtesy of Hill-Rom,
Charleston, SC)
FIGURE 21-6B A water-filled mattress helps

relieve pressure on the patient’s skin.
lar motion around a reddened area; frequent

turning; positioning to avoid pressure on irri-
tated areas; keeping linen clean, dry, and free
from wrinkles; applying protectors of sheep-
skin, lamb’s wool, or foam to bony promi-
nences such as heels and elbows; and using
egg crate, alternating-pressure mattresses (fig-
ure 21-6A), or water- or gel-filled mattresses
(figure 21-6B). Careful observation of the skin
during bathing or turning is essential. If a
pale, reddened, or blue–gray area is noted,
this should be reported immediately. FIGURE 21-7 A contracture is a tightening of a
muscle caused by lack of movement or usage of the
♦ Prevent contractures: A contracture (figure
muscle.
21-7) is a tightening or shortening of a muscle
usually caused by lack of movement or usage
of the muscle. Foot drop is a common contrac- nis shoes can be used to keep the foot in this
ture. It can be prevented in part by keeping the position. Range-of-motion (ROM) exercises,
foot at a right angle to the leg (figure 21-8). discussed in Information section 22:1, also
Footboards, foot supports, and high-top ten- help prevent contractures from developing.
792 CHAPTER 21
pulse rate serves as a control, or resting, rate. The

pulse rate is checked again immediately after
positioning the patient in the dangling position.
The third check occurs after the patient is returned
to a lying-down (supine) position in the bed. By
noting changes in the pulse rate, the health care
worker can determine how well the patient toler-
ates the procedure. In addition to taking the
pulse, observe the patient’s respiratory rate, bal-
ance (the patient may complain of vertigo or diz-
ziness), amount of perspiration, color, and other
similar characteristics. If the pulse rate shows an
abnormal increase, respirations become labored,
color becomes pale, increased perspiration is
noted, or the patient gets dizzy or very weak, the
patient should be returned immediately to the
supine, resting position.
FIGURE 21-8 Foot supports can be used to hold

the feet at right angles and prevent foot drop, a
common contracture. (Courtesy of J.T. Posey
TRANSFERS
Company) Patients are frequently transferred to wheelchairs,
chairs, or stretchers. Again, correct procedures
must be followed to prevent injury to both the
patient and the worker. Many different models of
TURNING wheelchairs and stretchers are available. It is
important to read the manufacturer’s instruc-
The patient confined to bed must be turned fre- tions regarding the operation of any given piece
quently. The patient’s position should be changed of equipment. If no instructions are available, ask
at least every 2 hours, if permitted by the physi- your immediate supervisor to demonstrate the
cian. Some agencies post a turning position correct operation of a particular wheelchair or
schedule by the patient’s bed. For example: 6 A.M.: stretcher.
Right side; 8 A.M.: Back; 10 A.M.: Left side; and 12 Mechanical lifts are frequently used to
NOON: Abdomen. Frequent turning provides exer- transfer weak or paralyzed patients. Again, it is
cise for the muscles. It also stimulates circulation, important to read the operating instructions pro-
helps prevent pressure ulcers and contractures, vided with the lift. Straps, clasps, and the sling
and provides comfort to the patient. Correct turn- should be checked carefully for any defects.
ing procedures must be followed to prevent injury Smooth, even movements must be used while
to both the patient and the health care worker. operating the lift. Patients are often frightened of
the lift and must be reassured that it is safe.
In home care situations, it is important to
DANGLING move unnecessary furniture out of the way dur-
ing transfers. If the bed does not raise or lower, it
If a patient has been confined to bed for a period is essential for the health care worker to observe
of time, the patient is frequently placed in a dan- correct body mechanics and to bend at the hips
gling position prior to being transferred from the and knees instead of the waist. It is possible to
bed. Dangling means sitting with the legs hang- rent hospital beds, wheelchairs, mechanical lifts,
ing down over the side of the bed. This allows the and other similar items for home care.
patient some time to adjust to the sitting posi- Before a patient is moved or transferred, the
tion. The pulse rate is checked at least three times health care worker must obtain approval or
during this procedure: before, during, and after orders from his or her immediate supervisor.
the dangling period. It is taken just before the Never move or transfer a patient without correct
patient is moved to the dangling position; this authorization.
During any move or transfer, it is important supervisor. The supervisor will determine whether
to watch the patient closely. Note changes in the move or transfer should be attempted.
pulse rate, respirations, and color. Observe for
signs of weakness, dizziness, increased perspira- STUDENT: Go to the workbook and complete
tion, or discomfort. If you note any abnormal the assignment sheet for 21:2, Positioning, Turn-
changes, return the patient to a safe and comfort- ing, Moving, and Transferring Patients. Then
able position and check with your immediate return and continue with the procedures.
PROCEDURE 21:2A
Aligning the Patient
Three pillows, two to three bath blankets, two
to three large towels, two to three washcloths
or small towels, protectors for bony promi-
nences, footboard, pen or pencil
Procedure
1. Obtain orders from your immediate
supervisor or check orders to obtain FIGURE 21-9 Correct alignment for a patient
permission for the procedure. positioned on the back in the horizontal recum-
bent or supine position.
3. Knock on the door and pause before b. Place a pillow under the head and
entering. Introduce yourself. Identify neck to provide support.
the patient. Explain the procedure to
the patient. c. A pillow or rolled blanket may be
placed under the lower legs, from the
4. Provide privacy. Close the door and knees to 2 inches above the heels to
screen the unit. provide support and keep the heels
5. Wash hands. off the bed.
6. Lock the wheels on the bed. Elevate the d. Protector pads may be placed on the
bed to a comfortable height. Lower the heels or elbows (figure 21-10).
bedrail or siderail on the side of the bed e. Toes should point upward. You may
where you are working. place a footboard, pillow, or rolled
CAUTION: If the bed does not raise to a blanket against the soles of the feet to
working height, use correct body achieve this. High-top tennis shoes
mechanics and bend from the hips and can also be placed on the feet to keep
knees, not the waist, to get close to the them at this angle.
patient. NOTE: Check the patient for comfort,
7. Align the patient who is lying on the safety, and support before leaving. Make
back in a supine position as follows (fig- sure no bony prominences are exposed
ure 21-9): and all body parts are supported.
a. Position the head in a straight line 8. Align the patient who is lying on the side
with the spine. (figure 21-11) as follows:
794 CHAPTER 21
PROCEDURE 21:2A
e. Use a footboard, pillow, rolled blan-
ket, or high-top tennis shoes to keep
the feet at right angles (90 degrees) to
the legs.
f. Rolled washcloths or foam rubber
balls may be placed in paralyzed
hands to prevent contractures.
g. Use pillows to support the back and/
or abdomen.
h. Protector pads may be placed on the
ankles, heels, and elbows.
CAUTION: Make sure that the patient’s
FIGURE 21-10 Foot protectors can help body is not twisted and that any one
prevent pressure ulcers on the heels. body part is not applying direct pressure
on any other body part.
NOTE: Check all aspects of the patient’s
position prior to leaving.
9. Align the patient who is lying on the
abdomen (in the prone position) as fol-
lows:
a. Place the head in direct line with the
spine.
b. Turn the head to one side. It may be
supported with a small pillow. Plac-
ing the pillow at an angle will keep it
away from the patient’s face.
c. A small pillow may be placed under
the waist for support.
d. Place a firm pillow under the lower
FIGURE 21-11 Correct alignment for a legs. This will slightly flex the knees.
patient positioned on the side.
e. The feet can be extended over the
end of the mattress so that they will
remain at right angles to the legs.
a. Place a small pillow under the head
They can also be supported in this
and neck for support.
position by pillows or rolled blankets
b. Flex the lower arm at the elbow. It (figure 21-12).
can be placed in line with the face.
f. Place the arms in line on either side
c. Support the upper arm, flexed at the of the head. Use pads to protect the
elbow, on a pillow or rolled blanket. elbows. Flex the elbows slightly for
d. Flex both knees slightly. Place a firm comfort.
pillow or rolled blanket between the NOTE: Check all aspects of position,
legs. The pillow should extend from comfort, and safety before leaving the
the upper leg to the ankle. patient.
PROCEDURE 21:2A
12. Wash hands.
13. Report that the procedure is complete
and/or record all required information
on the patient’s chart or the agency
form; for example, date; time; posi-
tioned on left side in correct alignment,
patient appears to be resting comfort-
ably; and your signature and title. Note
any unusual observations.
Practice
FIGURE 21-12 A large pillow can be used to Go to the workbook and use the
support the feet when the patient is lying in the evaluation sheet for 21:2A, Aligning
prone position. the Patient, to practice this
10. Observe all checkpoints prior to leaving have mastered this skill, sign the
the patient. Make sure the siderails are sheet and give it to your instructor
elevated (if indicated), the bed is at its
for further action.
lowest level, the call signal and supplies
are in easy reach, the patient is comfort-
able and in good body alignment, and
the area is neat and clean.
11. Properly replace all equipment not listed on the evaluation sheet, your
being used. instructor will grade your performance.
PROCEDURE 21:2B
Moving the Patient Up entering. Introduce yourself. Identify
in Bed the patient. Explain the procedure to
the patient.
Equipment and Supplies 3. Provide privacy. Close the door and
screen the unit.
Pen or pencil
4. Wash hands.
Procedure 5. Lock the bed (usually by way of wheel
locks) to prevent movement of the bed.
1. Obtain permission from your immedi- Elevate the bed to a comfortable height.
ate supervisor or check orders to make Lower the siderail nearest to you.
sure that the patient can be moved.
796 CHAPTER 21
PROCEDURE 21:2B
NOTE: Locks and siderails on beds vary. 9. Place your arm that is closest to the head
If you do not know how to lock a bed or of the bed under the patient’s head and
operate siderails, check with your imme- shoulders. Place your other arm under
diate supervisor. the patient’s hips.
6. Lower the head of the bed. Remove all CAUTION: If the patient is unable to
pillows. One pillow can be placed against help, get someone else to assist you. Do
the headboard of the bed to prevent not risk injury to yourself or to the
injury to the patient’s head while mov- patient.
ing the patient up in bed.
10. If the patient can assist, arrange a signal.
NOTE: Observe the patient for respira- For example, say, “On the count of three,
tory distress. push with your feet.”
CAUTION: If any breathing difficulty is 11. Use the signal. Slide the patient toward
noted, immediately raise the head of the the head of the bed. Shift your weight
bed. Check with your supervisor before from the rear leg to the forward leg at
proceeding. the same time that you slide the
patient.
7. Ask the patient to flex the knees and
brace both feet firmly on the bed. NOTE: Use the weight of your body to
move the patient. Avoid back strain.
NOTE: If necessary, help by flexing the
patient’s knees and bracing the patient’s CAUTION: If you are not able to move
feet on the bed. the patient, get help.
8. Face the head of the bed. Get a broad 12. If the patient is too heavy for one person
base of support by putting one foot to lift, or the patient is unable to help,
ahead of the other. Get close to the two people should use a lift sheet to
patient and bed (figure 21-13) move the patient.
NOTE: Use proper body mechanics a. One person gets on each side of the
throughout the procedure. bed. Each person positions one hand
on the lift sheet by the patient’s shoul-
ders, and the other hand by the
patient’s hips.
b. Each person rolls the edges of the lift
sheet inward close to both sides of
the patient’s body (figure 21-14A).
c. At a given signal, such as one-two-lift,
the two health care workers lift the
sheet and patient, and move the
patient to the head of the bed (figure
21-14B).
d. After the patient is positioned, each
worker tucks the lift sheet back into
the side of the bed.
13. Leave the patient in good body align-
ment. Make sure the patient is comfort-
FIGURE 21-13 Get close to the patient and able.
bed while moving a patient up in bed.
PROCEDURE 21:2B
14. Elevate the siderails (if indicated). Place
the call signal and any needed supplies
within easy reach of the patient. Lower
the bed to its lowest level.
15. Replace all equipment. Make sure the
area is neat and clean.
16. Wash hands.
17. Report that the patient has been moved
up in bed and/or record all required
information on the patient’s chart or the
FIGURE 21-14A To use a lift sheet to move a agency form; for example, date; time;
patient, two health care workers should roll the
moved to head of bed, tolerated proce-
edges of the sheet toward the patient.
dure well; and your signature and title.
Note any unusual observations.
Practice
evaluation sheet for 21:2B, Moving
the Patient Up in Bed, to practice
FIGURE 21-14B At a given signal, the Final Checkpoint Using the criteria
workers lift and move the sheet and patient to listed on the evaluation sheet, your
the head of the bed. instructor will grade your performance.
PROCEDURE 21:2C
Turning the Patient Procedure
Away to Change 1. Obtain permission from your immedi-
ate supervisor or check orders to make
Position sure that the patient can be turned.
Equipment and Supplies 2. Knock on the door and pause before

entering. Introduce yourself. Identify
Pen or pencil the patient. Explain the procedure.
798 CHAPTER 21
PROCEDURE 21:2C
3. Provide privacy. Close the door and
screen the unit.
4. Wash hands.
5. Lock wheels to prevent movement of
the bed. Elevate the bed to a comfort-
able height.
6. Lower the siderail nearest to you. Make
sure the opposite siderail is raised and
locked securely.
7. The patient should be lying on the side
of the bed close to you. If so, proceed to
step 8. If the patient is at the center or
close to the far side of the bed, move the
patient as follows: FIGURE 21-15A Place one arm under the
patient’s shoulders and the other arm under the
a. Place one hand under the patient’s patient’s hips.
head and neck. Place your other hand
under the patient’s upper back. Slide
the upper part of the patient’s body 10. Use a smooth, even motion to roll the
toward you. patient away from you and onto his or
b. Place both hands under the patient’s her side (figure 21-15B).
hips. Slide the hips toward you. NOTE: Explain what you are doing to
c. Place both hands under the patient’s the patient.
upper and lower legs. Slide the legs 11. Place your hands under the patient’s
toward you. head and shoulders. Draw the head and
CAUTION: If you are not able to move shoulders back toward the center of the
the patient, get help. bed.
CAUTION: Check the opposite siderail.

Make sure it is up before proceeding.
8. Ask the patient to place his or her arms
across the chest and move the proximal
leg (the one closest to you) over the
other leg.
NOTE: This will make it easier to turn
the patient and helps prevent injury.
CAUTION: Do not cross the legs if the
patient had hip replacement surgery.
9. Get close to the patient by bending your
knees and keeping your back straight.
Position your feet to provide a broad
base of support. Place one arm under
the patient’s shoulders. Place your FIGURE 21-15B Use a smooth, even motion
opposite hand under the patient’s hips to roll the patient away from you and onto the
(figure 21-15A). patient’s side.
PROCEDURE 21:2C
12. Place your hands under the patient’s 18. Report that patient has been turned
hips and gently pull them back toward and/or record all required information
the center of the bed. on the patient’s chart or the agency
form; for example, date, time, turned on
13. Place your hands under the patient’s
left side and positioned in correct align-
legs and pull them back toward the cen-
ment, and your signature and title. Note
ter of the bed.
14. Place a pillow behind the patient’s back,
between the legs to align the hips, and
under the upper arm. Make sure the
patient is comfortable and in good
alignment.
Practice
15. Elevate the siderails (if indicated) before evaluation sheet for 21:2C, Turning
leaving the patient. Make sure that the the Patient Away to Change
call signal and other needed supplies Position, to practice this procedure.
are within easy reach of the patient. When you believe you have
Lower the bed to its lowest level. mastered this skill, sign the sheet
16. Replace all equipment. Leave the area and give it to your instructor for
neat and clean. further action.
17. Wash hands.
PROCEDURE 21:2D
3. Provide privacy. Close the door and
Turning the Patient screen the unit.
Inward to Change 4. Wash hands.
Position 5. Lock the wheels of the bed to prevent
movement. Elevate the bed to a com-
Equipment and Supplies fortable height.
Pen or pencil 6. Lower the siderail nearest to you.
7. If the patient is too close to the near side
Procedure of the bed, move him or her to the oppo-
site side as follows:
1. Obtain permission from your immedi-
ate supervisor or check orders to make a. Place one hand under the patient’s
sure that the patient can be turned. head and shoulders and the other
hand under the patient’s back. Slide
2. Knock on the door and pause before the upper part of the body toward the
entering. Introduce yourself. Identify opposite side of the bed.
the patient. Explain the procedure.
800 CHAPTER 21
PROCEDURE 21:2D
b. Place both hands under the patient’s CAUTION: Observe proper body
hips. Slide the hips toward the oppo- mechanics at all times.
site side of the bed.
11. Raise and secure the siderail. Go to the
c. Place both hands under the patient’s opposite side of the bed and lower the
legs. Slide the legs toward the oppo- siderail.
8. Instruct the patient to cross his or her head and shoulders and draw the head
arms on the chest. Place the patient’s leg and shoulders back toward the center of
that is farthest from you on top of the the bed.
leg that is nearest to you.
NOTE: This prevents injury to the hips and draw them toward the center
patient’s arms and legs. of the bed (figure 21-16B).
CAUTION: Do not cross the legs if the 14. Place your hands under the patient’s
patient had hip replacement surgery. legs and draw them toward the center of
the bed.
9. Get close to the patient by bending your
knees and keeping your back straight. 15. Place pillows behind the patient’s back,
Position your feet to provide a broad between the legs, and under the upper
base of support. Place your hand that is arm to position the patient in good body
closest to the head of the bed on the alignment (figure 21-16C). Make sure
patient’s far shoulder. Place your other that the patient is comfortable.
hand behind the patient’s hip. Use your
16. Elevate the siderail, if indicated. Place
knee to brace your body against the side
the call signal and other necessary sup-
of the bed.
plies within easy reach of the patient.
10. Use a gentle, smooth motion to roll the Lower the bed to its lowest level.
patient toward you (figure 21-16A).
FIGURE 21-16A With your FIGURE 21-16B Place your FIGURE 21-16C Place a
hands on the patient’s far hands under the patient’s hips pillow behind the patient’s back,
shoulder and hip, use a gentle, and draw them toward the between the legs to align the
smooth motion to roll the patient center of the bed. hips, and under the upper arm.
toward you.
PROCEDURE 21:2D
17. Replace all equipment. Leave the area
neat and clean.
18. Wash hands. Practice
19. Report that patient has been turned Go to the workbook and use the
and/or record all required information evaluation sheet for 21:2D, Turning
on the patient’s chart or the agency the Patient Inward to Change
form; for example, date, time, turned on Position, to practice this procedure.
right side and positioned in correct When you believe you have
alignment, and your signature and title. mastered this skill, sign the sheet
Note any unusual observations. and give it to your instructor for
further action.
PROCEDURE 21:2E
8. Check the patient’s radial pulse. This
Sitting Up to Dangle reading will serve as a guideline on how
the patient tolerates the procedure.
Equipment and Supplies 9. Slowly elevate the head of the bed to a
Footstool (if needed), bath blanket, robe sitting position. Provide time for the
and/or slippers, pen or pencil patient to adjust to this position.
10. Put a bedjacket or robe on the patient.
Procedure Prevent unnecessary exposure.
1. Check orders or obtain authorization 11. Get close to the patient by bending your
from your immediate supervisor. Orders knees and keeping your back straight.
usually state the length of time the Position your feet to provide a broad base
patient should dangle. of support. Place your arm that is nearest
to the head of the bed around the patient’s
2. Assemble equipment. shoulders. Place your other arm under
3. Knock on the door and pause before the patient’s knees (figure 21-17A). Slowly
entering. Introduce yourself. Identify and smoothly rotate the patient toward
the patient. Explain the procedure. the side of the bed (figure 21-17B).
4. Provide privacy. Close the door and CAUTION: Use proper body mechanics
screen the unit. at all times.
5. Wash hands. CAUTION: Stand in front of the patient
to prevent falls.
6. Lock bed wheels to prevent movement
of the bed. 12. Use the bath blanket to cover the
patient’s lap and legs. Put slippers on
7. Lower the bed to its lowest level. Lower the patient. Rest the patient’s feet on a
the siderail on the side where the patient footstool (if necessary).
is to dangle.
802 CHAPTER 21
PROCEDURE 21:2E
17. Place one arm around the patient’s
shoulders and your other arm under the
patient’s knees. Gently and slowly return
the patient to the bed.
CAUTION: Use correct body mechanics.
18. Remove the patient’s robe.
19. Slowly lower the head of the bed.
20. Position the patient in good alignment.
21. Check the patient’s radial pulse. Note
any major changes. Report any changes
FIGURE 21-17A Place one arm around the immediately.
patient’s shoulders and the other arm under the
patient’s knees. 22. Observe all checkpoints before leaving
the patient. Make sure the siderails are
elevated (if indicated), the bed is at its
lowest level, the call signal and other
supplies are within easy reach, and the
area is neat and clean.
23. Wash hands.
24. Report that the patient has dangled
form; for example, date; time; sat on
side of bed for 15 minutes, P 72 strong
and regular at start of procedure, P 78
FIGURE 21-17B Slowly rotate the patient strong and regular at end, knees and
toward the side of the bed. legs flexed and extended, tolerated pro-
13. Check the patient’s radial pulse. Note cedure well; and your signature and
any signs of distress, such as pale color, title. Note any unusual observations.
increased perspiration, labored respira-
tions, weakness, dizziness, or nausea.
CAUTION: If any of these signs are
noted, go immediately to step 17 and Practice
return the patient to the original posi- Go to the workbook and use the
tion in bed. evaluation sheet for 21:2E, Sitting
14. Instruct the patient to flex and extend Up to Dangle, to practice this
the legs and feet. This increases circula- procedure. When you believe you
tion to the area and stimulates the mus- have mastered this skill, sign the
cles. sheet and give it to your instructor
for further action.
15. Have the patient dangle for the time
ordered or as the patient’s condition
permits.
16. When the time is up, remove the patient’s listed on the evaluation sheet, your
slippers and the bath blanket. instructor will grade your performance.
PROCEDURE 21:2F
Transferring a Patient
to a Chair or
Wheelchair
NOTE: Wheelchairs vary slightly. Read the
manufacturer’s instructions or ask your
immediate supervisor to demonstrate correct
operation of the footrests, wheel locks, and
other parts.

Wheelchair or chair, bathrobe, transfer belt, FIGURE 21-18A Lock the wheels and elevate
one to two bath blankets, slippers, pen or the footrests before moving a patient to a wheel-
pencil chair.
Procedure
NOTE: For additional comfort and
1. Obtain orders from your immediate warmth, a bath blanket can be folded
supervisor or check physician’s orders lengthwise and placed in the chair or
to obtain authorization. wheelchair.
2. Assemble equipment. 8. Lock the bed to prevent movement.
3. Knock on the door and pause before Lower the bed to its lowest level.
entering. Introduce yourself. Identify 9. Slowly elevate the head of the bed.
10. Lower the siderail on the side that the
the patient.
patient is to exit from the bed.
4. Close the door and screen the unit to
11. If the patient needs a robe, put the robe
provide privacy for the patient.
on the patient. Fanfold the bed linen to
5. Wash hands. the foot of the bed.
6. Position the wheelchair or chair. It can NOTE: Avoid exposing the patient dur-
be placed at the head of the bed facing ing this procedure.
the foot or at the foot of the bed facing
12. Assist the patient to a sitting position on
the head. Positioning often depends on
the side of the bed with his or her feet
other equipment in the room.
flat on the floor. Observe for any signs of
NOTE: Whenever possible, the chair distress. Note color, pulse rate, breath-
should be positioned so that it is secure ing, and other similar signs. Put socks
against a wall or solid furniture and will and shoes or slippers with nonslip soles
not slide backward. on the patient. Put a transfer (gait) belt
7. Securely lock the wheels of the wheel- on the patient following procedure
chair. Raise the footrests so that they are 22:2A.
out of the way (figure 21-18A). NOTE: Refer to Procedure 21:2E on dan-
CAUTION: Double-check the locks on gling.
the wheelchair. CAUTION: If the patient is weak or too
heavy, get help.
804 CHAPTER 21
PROCEDURE 21:2F
CAUTION: If distress is noted, return
the patient to bed immediately.
CAUTION: Use proper body mechan-
ics.
13. Keep your back straight. Place one hand
on each side of the belt using an under-
hand grasp. Face the patient and stand
close to the patient. Position your feet to
provide a broad base of support. If the
patient has a weak leg, support the leg
by positioning your knee against the
patient’s knee or by blocking the patient’s
foot with your foot.
NOTE: If the use of a transfer belt is con-
traindicated, place your hands under
the patient’s arms and around to the
back of the shoulders to provide sup-
port.
14. Arrange a signal with the patient, such
as counting to three. Instruct the patient
to push against the bed with his or her
hands to rise to a standing position.
15. At the given signal, assist the patient to a
standing position. Lift up on the belt
while the patient pushes up from the FIGURE 21-18B Lift up on the belt while the
bed (figure 21-18B). Place your knees patient pushes up from the bed.
and feet firmly against the patient’s
knees and feet to provide support. chair, taking care not to hit the patient’s
16. Keeping your hands in the same posi- feet.
tion, help the patient turn by using sev- NOTE: Observe for any signs of distress.
eral pivot steps until the backs of his or
her legs are touching the seat of the 19. Remain with the patient until you are
chair (figure 21-18C). sure there are no problems. If you leave
the patient seated in a wheelchair or
17. Ask the patient to place his or her hands chair, make sure that the call signal and
on the armrests and to bend at the knees other supplies are within easy reach.
as you gradually and slowly lower the Leave the area neat and clean. Check on
patient to a sitting position in the chair the patient at frequent intervals.
(figure 21-18D).
20. If you are transporting the patient in the
CAUTION: Bend at the hips and knees wheelchair, observe the following rules:
and keep your back straight.
a. Walk on the right side of the hall or
18. Position the patient comfortably. corridor.
Remove the transfer belt. Use a bath
blanket to cover the patient’s lap and b. Slow down and look for other traffic
legs. Lower the footrests on the wheel- at doorways and intersections (figure
21-19).
PROCEDURE 21:2F
FIGURE 21-18C Help the patient turn until FIGURE 21-18D Gradually and slowly lower
the backs of his or her legs are touching the the patient to a sitting position in the chair.
seat of the chair.
c. To enter an elevator, turn the chair 22. Position the patient in good body align-
around and back into the elevator. ment after returning him or her to bed.
d. To go down a steep ramp, turn the 23. Observe all checkpoints before leaving
chair around and back down the the patient: elevate the siderails (if indi-
ramp. cated), lower the bed to its lowest level,
and place the call signal and other sup-
e. Use the weight of your body to push
plies within easy reach of the patient.
the chair. Stand close to the chair.
24. Replace all equipment used. Wipe the
f. Watch the patient closely for signs of
wheelchair with a disinfectant and
distress while transporting.
return it to its proper place. Leave the
21. To return the patient to bed, reverse the area neat and clean.
procedure, beginning by putting a trans-
25. Wash hands.
fer belt on the patient and raising the
footrests (step 18). 26. Report that the patient was transferred
to a wheelchair and/or record all
CAUTION: Be sure the wheels are locked
required information on the patient’s
before helping the patient out of the
chart or the agency form; for example,
wheelchair. Lock the bed to prevent
date; time; transferred to chair, sat in
movement.
806 CHAPTER 21
PROCEDURE 21:2F
chair for 30 minutes, tolerated well; and
your signature and title. Note any
unusual observations.
Practice
Transferring a Patient to a Chair or
Wheelchair, to practice this
for further action.
FIGURE 21-19 Watch closely for other traffic

at doorways and intersections.
PROCEDURE 21:2G
Transferring a Patient entering. Introduce yourself. Identify
to a Stretcher the patient. Explain the procedure to
the patient.
Equipment and Supplies 4. Provide privacy. Close the door and
screen the unit.
Stretcher with siderails and safety belt(s),
bath blanket, pen or pencil 5. Wash hands.
NOTE: Because this procedure requires more 6. Elevate the bed to the level of the
than one person, it is best to determine what stretcher. Lock the bed wheels to pre-
tasks each of the assistants will perform vent movement of the bed. Lower the
before beginning the procedure. siderail on the side of the transfer.
7. Place a bath blanket over the patient.
Procedure Fold bed linen to the foot of the bed.
1. Check physician’s orders or obtain NOTE: Avoid exposing the patient.
authorization from your immediate 8. Place the stretcher next to the bed.
supervisor for the transfer. The bed and the stretcher should be
2. Assemble equipment. Cover the stretch- parallel.
er with a clean sheet. 9. Lock the wheels of the stretcher.
PROCEDURE 21:2G
CAUTION: In addition to the locks, use 11. If the patient is very weak, paralyzed,
the weight of your body to hold the semiconscious, or unconscious, pro-
stretcher against the bed during this ceed as follows:
procedure.
a. Obtain the assistance of three or four
CAUTION: Use correct body mechanics other people.
at all times.
b. Position a lifting sheet or blanket
10. If the patient is conscious and capable under the patient extending from the
of moving unassisted, proceed as fol- patient’s head and neck to the feet.
lows:
c. Position two or three people by the
a. Reach across the stretcher and hold stretcher and one or two people on
up the bath blanket. the open side of the bed.
b. Ask the patient to slide from the bed d. Roll the sides of the lifting sheet or
to the stretcher. Hold the stretcher blanket close to the patient’s body.
against the bed (figure 21-20).
e. Using overhand grasps, one assistant
c. If the patient needs assistance, help should grasp the sheet by the patient’s
by moving first the patient’s head and head and shoulders. The second assis-
shoulders, then the patient’s hips, tant should grasp the sheet by the
and finally the patient’s legs and feet. waist and lower hip. The third assis-
tant should grasp the sheet by
CAUTION: Make sure that the bed and
the patient’s thighs and legs. The
stretcher wheels are locked and stabi-
assistant(s) on the open side of
lized while the patient is being moved
the bed should grasp the sheet at the
toward you.
patient’s head and hips (figure 21-21).
CAUTION: If the patient is too heavy or
f. At a given signal, all assistants should
unable to assist with the move, obtain
lift the sheet slightly to gently slide
help.
the patient from the bed to the
stretcher.
NOTE: Some facilities use slider boards
instead of a lifting sheet or blanket.
12. Position the patient comfortably on the
stretcher.
13. Lock the safety belt(s). Raise both side-
rails of the stretcher.
14. To transport the patient, two persons
should direct the stretcher (one at the
head and one at the foot).
a. Unlock the wheels of the stretcher.
Move slowly.
b. The stretcher patient always travels
feetfirst.
FIGURE 21-20 Hold up the bath blanket and
use the weight of your body to hold the stretcher c. Walk on the right side of the hall.
against the bed while the patient is moving to
the stretcher.
808 CHAPTER 21
PROCEDURE 21:2G
the patient: position the patient in cor-
rect alignment, elevate the siderails (if
indicated), lower the bed to its lowest
level, place the call signal and other sup-
plies within easy reach of the patient,
and leave the area neat and clean.
17. Remove the sheet from the stretcher
and place the sheet in a linen hamper.
Use a disinfectant to wipe the stretcher.
Replace all equipment used. Leave the
area neat and clean.
18. Wash hands.
19. Report that the patient was transferred
to a stretcher and/or record all required
agency form; for example, date; time;
transferred to stretcher and transported
to radiology department, tolerated pro-
cedure well; and your signature and
title. Note any unusual observations.
FIGURE 21-21 Three to five people can use

a lift sheet or blanket to move a patient from the
bed to the stretcher.
d. Watch for cross traffic at doorways

and intersections.
e. When going down an incline, the per-
son at the foot of the stretcher should
Practice
go backward and use body weight to Go to the workbook and use the
control the stretcher. evaluation sheet for 21:2G,
Transferring a Patient to a Stretcher,
f. To enter an elevator, push the correct to practice this procedure. When you
button to keep the elevator door believe you have mastered this skill,
open. Back the stretcher into the ele- sign the sheet and give it to your
vator so that the head end enters first. instructor for further action.
To leave the elevator, push the button
to keep the door open, and push the
stretcher out feet end first.
15. To return the patient to bed, reverse the
procedure, beginning with locking the
wheels of the stretcher and bed and
unlocking the safety belt(s) (see step 13).
CAUTION: Always check the wheel locks listed on the evaluation sheet, your
before transferring patients. instructor will grade your performance.
PROCEDURE 21:2H
Label the defective mechanical lift with
Using a Mechanical a warning or lock-out and notify your
Lift to Transfer a supervisor immediately.
Patient 3. Knock on the door and pause before
NOTE: Mechanical lifts vary slightly. Read the the patient. Explain the procedure.
manufacturer’s instructions or ask your Reassure the patient, as needed.
immediate supervisor to demonstrate the
correct operation of the lift. NOTE: Patients are often apprehensive
about being transferred by lift. It is impor-
CAUTION: The manufacturer will indi- tant that they be as relaxed as possible
cate the weight limits for the mechani- for the transfer. Constant reassurance
cal lift. Do not use the mechanical lift if and encouragement are necessary.
the patient weighs more than the weight
limit. 4. Close the door and screen the unit for
privacy during the transfer.
Equipment and Supplies 5. Wash hands.
Mechanical lift with straps and sling, bath 6. Position the chair or wheelchair next to
blanket, chair or wheelchair, pen or pencil the foot of the bed, with the open seat
facing the head of the bed. Lock the
NOTE: If the lift is being used to transfer a wheels of the wheelchair or ask another
patient to a bathtub or shower area, a chair or health team member to hold the chair
wheelchair is not required. in position. Raise the footrests to the
CAUTION: Some facilities require that upright position.
two health care providers perform this 7. Lock the wheels of the bed. Lower the
procedure. One person operates the lift siderail on the side of the transfer.
while the second person guides the
movements of the patient. Follow 8. Turn or move the patient to position the
agency policy for this procedure. sling under the patient. The sling should
be positioned under the shoulders, but-
Procedure tocks, and thighs. Make sure that the
sling is smooth and that the center is
1. Obtain orders from your immediate near the center of the patient’s back (fig-
supervisor or check physician’s orders ure 21-22A).
to obtain authorization. 9. Attach the suspension straps to the
2. Assemble equipment. Read the operat- sling. Insert the hooks from the inside of
ing instructions provided with the the sling to the outside to keep the open
mechanical lift or ask your immediate end of the hooks away from the patient’s
supervisor to demonstrate operation of body (figure 21-22B). Make sure that the
the lift. Check the straps, sling, and any straps are not tangled or twisted. If
clasps to make sure there are no defects. clasps are present on the hooks, make
Check the hydraulic unit and look for sure they are secure.
evidence of oil leaks. 10. Position the mechanical lift over the
CAUTION: Do not use the lift if straps or bed. Open the base of the lift to its wid-
sling are torn or defective, if clasps are est position to provide a broad base of
not secure, or if oil is leaking from the support.
hydraulic unit. Serious injury may result.
810 CHAPTER 21
PROCEDURE 21:2H
FIGURE 21-22A Position the sling under the FIGURE 21-22C Position the mechanical lift
patient’s shoulders, buttocks, and thighs. over the bed.
12. Tell the patient that he or she will be

lifted from the bed. Constantly reasure
the patient.
13. Turn the crank or use the hydraulic con-
trol to slowly raise the patient slightly
above the bed. Check the straps, sling,
and position of the patient to be sure
that the patient is suspended securely
by the lift. Then continue to raise the
patient as needed until you can slowly
turn the lift to move the patient away
from the bed and into position over the
chair or wheelchair. Keep all movements
as smooth and even as possible (figure
21-22D).
FIGURE 21-22B Insert the hooks from the
inside of the sling to the outside. CAUTION: Move slowly to prevent jerk-
ing motions that may frighten the
patient.
11. Attach the straps to the frame of the lift
(figure 21-22C). Check to make sure that 14. Slowly lower the lift to position the
the suspension straps are locked to the patient in the chair or wheelchair. Guide
frame or attached securely. Make sure the patient’s legs into position on the
that the straps are not tangled or twisted. chair (figure 21-22E).
Position the patient’s arms inside the 15. Unhook the suspension straps from the
straps. Encourage the patient to keep sling. The sling is usually left in position
his or her arms folded across the chest under the patient. Carefully move the
to keep the arms inside the straps. lift away from the patient.
PROCEDURE 21:2H
17. To return the patient to bed, reverse the
procedure. Begin by making sure the
wheels of the chair and bed are locked.
Attach the suspension straps securely to
the sling.
rect alignment, elevate the siderails (if
indicated), lower the bed to its lowest
level, place the call signal and other sup-
plies within easy reach of the patient,
19. Use a disinfectant to wipe the mechani-
cal lift. Properly replace all equipment
used. Leave the area neat and clean.
20. Wash hands.
FIGURE 21-22D Use a smooth motion to lift 21. Report that the patient was transferred
the patient out of the bed.
to a chair or wheelchair using a mechan-
ical lift and/or record all required infor-
mation on the patient’s chart or the
transferred to chair with mechanical lift,
patient seemed slightly apprehensive at
start of procedure but relaxed while in
chair; and your signature and title. Note
Practice
evaluation sheet for 21:2H, Using a
Mechanical Lift to Transfer a
FIGURE 21-22E Lower the lift slowly to Patient, to practice this procedure.
position the patient in the wheelchair. When you believe you have
CAUTION: Be careful not to injure the mastered this skill, sign the sheet
patient with the straps or lift while mov- and give it to your instructor for
ing the lift away from the chair. further action.
16. Use the blanket to cover the patient.
Lower the footrests of the wheelchair
and position the patient’s feet in a com-
fortable position. If the patient is in a Final Checkpoint Using the criteria
chair, slippers can be put on the patient’s listed on the evaluation sheet, your
feet. instructor will grade your performance.
812 CHAPTER 21
♦ Bed cradle: A cradle is placed on a bed under

21:3 INFORMATION the top sheets to prevent bed linen from touch-
Bedmaking ing parts of the patient’s body. A cradle fre-
quently is used for patients with burns, skin
Making beds correctly is a task performed ulcers, lesions, blood clots, circulatory dis-
by many health care workers. A correctly ease, fractures, surgery on legs or feet, and
made bed provides comfort and protection for other similar conditions.
the patient confined to bed for long periods of
time. Therefore, care must be taken when beds Draw sheets are half sheets that are frequently
are made. The bed linen must be free of all wrin- used on beds. A draw sheet extends from the
kles. Wrinkles cause discomfort and can lead to patient’s shoulders to the patient’s knees. The
the formation of pressure ulcers. draw sheet is used to protect the mattress. If
Mitered corners are used to hold the linen soiled, the draw sheet can be changed readily
firmly in place. Mitering corners is a special fold- without changing the bottom sheet of the bed. In
ing technique that secures the linen under the some settings, disposable bed protectors, fre-
mattress (figure 21-23). Mitered corners are also quently called underpads, are placed under the
used for linen placed on stretchers and examina- patient to protect the sheets instead of using draw
tion tables. Some agencies and homes use fitted sheets. Draw sheets are sometimes used as lift
contour sheets for bottom sheets. Mitered cor- sheets.
ners would not be used with these sheets, but To prevent injury to yourself, you must
would be used with top sheets. observe correct body mechanics while mak-
Following are examples of the types of beds ing beds. It is also important to conserve time
that you may be required to make: and energy. Keeping linen arranged in the order
♦ Closed bed: This is a bed made following the of use is one way to conserve time and energy. In
discharge of a patient and after terminal clean- addition, most beds are made completely first on
ing of the unit. Its purpose is to keep the bed one side and then on the other side. This limits
clean until a new patient is admitted. unnecessary movement from one side of the bed
to the opposite side.
♦ Open bed: A closed bed is converted to an It is also important to limit the movement of
open bed by fanfolding (folding like accor- organisms and, therefore, the spread of infection
dion pleats) the top sheets. This is done to while making beds. Roll dirty or soiled linen while
“welcome” a new patient. It is also done for removing it from the bed. Hold dirty linen away
patients who are ambulatory or out of bed for from your body and place it in a linen hamper,
short periods of time. cart, or bag immediately. Never place dirty linen
♦ Occupied bed: This is a bed made while the on the floor. Some facilities do not allow linen
patient is in the bed. This is usually done after hampers or carts in a patient’s room. The hamper
the morning bath. or cart is left in the hall. Soiled linen is placed in a
pillowcase or plastic bag, carried to the hall, and
A B placed in the hamper or cart. Wash your hands
after handling dirty linen and before handling
clean linen. Clean linen should be stored in a
closed closet or on a covered linen cart. Never
allow clean linen to contact your uniform. Never
bring extra linen to the patient’s room because it
C D is then considered contaminated and cannot be
used for another patient. Avoid shaking clean
sheets. Unfold them gently. Place the open end of
the pillowcase away from the door. This looks
neater and also helps prevent the entrance of
organisms from the hall.
If linen is contaminated by blood, body flu-
FIGURE 21-23 Steps for making a mitered ids, secretions, excretions, urine, or feces,
corner. observe standard precautions (discussed in
Chapter 14:4). Wash your hands frequently and ond bag is necessary because wet linen may dis-
wear gloves while handling contaminated linen. solve the water-soluble bag before it reaches the
Follow agency policy for proper disposal of linen. laundry department. The health care worker
Many agencies have special self-dissolving plas- must be alert at all times to prevent the spread of
tic laundry bags that dissolve during the washing infection by contaminated linen.
process. The contaminated linen is placed in the
bag, and the bag is sealed. The bag is then placed STUDENT: Go to the workbook and complete
inside another plastic bag and labeled before the assignment sheet for 21:3, Bedmaking. Then
being sent to the laundry department. The sec- return and continue with the procedure.
PROCEDURE 21:3A
CAUTION: Never place dirty linen on
Making a Closed Bed the floor.
NOTE: Some facilities do not allow linen
Equipment and Supplies hampers or carts in a patients’s room.
Two large sheets (or one large sheet and one The hamper or cart is left in the hall.
fitted sheet), draw sheet (if used), spread, pil- Soiled linen is placed in a pillowcase or
low, pillowcase, blanket (as necessary), linen plastic bag, carried to the hall, and
hamper, cart, or bag placed in the hamper or cart.
6. Unfold the bottom sheet right side up.
Procedure Place the small hem even with the foot
of the mattress (figure 21-24A). The cen-
1. Assemble equipment. ter fold should be at the center of the
2. Wash hands. bed. The wide hem should be at the
head of the bed.
3. Arrange the clean linen on a chair in the
order in which the linen is to be used. CAUTION: Avoid shaking the sheet
because doing so spreads germs.
NOTE: This simplifies the procedure
and prevents excessive handling of NOTE: If a fitted sheet is used, it is posi-
linen. tioned on the bed, with the contour cor-
ners positioned at the head and foot of
4. Elevate the bed to a comfortable height. the mattress. Fit one contour corner
Lock the wheels to prevent movement. smoothly around the foot of the mat-
5. If dirty linen is on the bed, remove the tress. Then fit the contour corner around
linen. Roll it into a compact bundle. the head of the mattress.
Hold the linen away from your body. NOTE: Complete one side of the bed
Place it in the linen hamper, bag, or entirely before going to the opposite
cart. side. This saves time and energy.
CAUTION: Prevent spread of organisms 7. Tuck 12–18 inches of the sheet under
and infection. Wear gloves and observe the mattress at the head of the bed (fig-
standard precautions if linen is contam- ure 21-24B).
inated with blood, body fluids, secre-
tions, or excretions. If the mattress is 8. Make a mitered corner as follows:
soiled, wipe it with a disinfectant. After a. Pick up the sheet approximately 12
removing contaminated linen, remove inches from the head of the bed.
the gloves and wash your hands before
handling clean linen.
814 CHAPTER 21
PROCEDURE 21:3A
b. Form a triangle with a 45-degree e. Tuck the folded part under the mat-
angle on top of the mattress (figure tress (figure 21-24E).
21-24C).
9. Tuck in the side of the sheet by working
c. Tuck the lower portion under the from the head to the foot of the bed (fig-
mattress (figure 21-24D). ure 21-24F).
d. Hold the fold with one hand and CAUTION: Avoid injury. Use correct
bring the triangle down with the body mechanics. Work close to the bed
other. and with a broad base of support.
A B
C D
FIGURE 21-24 (A) Position the small hem of the bottom sheet even with the foot of the mattress.
(B) Tuck 12–18 inches of the sheet under the mattress at the head of the bed. (C) To make a mitered
corner, pick up the sheet approximately 12 inches from the head of the bed and form a triangle with a
45-degree angle. (D) Tuck the bottom part of the triangle under the mattress.
PROCEDURE 21:3A
10. Place a draw sheet, if used, in the center
of the bed, approximately 14–16 inches
from the head of the bed. Tuck the draw
sheet in at the side of the bed.
NOTE: Make sure the tucks are secure
and as far under the mattress as possi-
ble. This helps hold the sheets in place.
NOTE: Not all agencies use draw sheets.
E
Underpads may be placed on the bed to
prevent soiling of the linen.
11. Place the top sheet on the bed, wrong
side up. Use the center fold to center the
sheet. The wide hem should be even
with the top edge of the mattress.
12. Tuck the top sheet over the foot of the
mattress.
F 13. Make a mitered corner as previously
instructed.
14. Tuck the side of the sheet under the
mattress to the center of the bed only.
15. If a blanket is used, it can be placed on
the bed in the same manner as the top
sheet. The top sheet and blanket can be
tucked in at the same time.
16. Place the spread on the bed right side
up. The top edge should be even with
G
the top edge of the mattress. Use the
center fold to center the spread.
17. Tuck the spread under the mattress at
the foot of the bed.
NOTE: The top sheet, blanket, and
spread can all be placed on the bed at
the same time. They are then tucked in
as one unit at the bottom of the bed, and
a mitered corner is made with all of the
H linen (figure 21-24G).
FIGURE 21-24 (E) Bring the triangle down 18. Make a mitered corner but do not tuck
and tuck it firmly under the mattress to finish the
the final end under the side of the mat-
mitered corner. (F) Tuck the side of the sheet
tress. Let the triangle hang loose (figure
under the mattress. (G) The top sheet, blanket,
21-24H).
and spread can be tucked under the mattress
as one unit and secured with a single mitered 19. Go to the opposite side of the bed. From
corner. (H) After making a mitered corner, allow the side, fanfold the top covers to the
the top sheet, blanket, and spread to hang free center of the bed so you can work with
on the side of the mattress. the bottom sheet.
816 CHAPTER 21
PROCEDURE 21:3A
20. Tuck the bottom sheet under the head
of the mattress. Make a mitered corner.
21. Work from the head of the bed to the
foot to tuck in the side of the sheet. Pull
the sheet gently to remove all wrinkles
before tucking in the side.
22. Grasp the draw sheet in the center. Pull
gently to remove wrinkles. Tuck in firmly
at the side.
23. Tuck in the top sheet (and blanket) at
the foot of the bed. Make a mitered cor-
ner. Remove all wrinkles and tuck in at
the side up to the center of the bed
only.
24. Tuck in the spread at the foot of the bed.
Make a mitered corner but do not tuck
in the final fold. Let it hang.
25. Line up all sheets so they are smooth and
free of wrinkles. If a blanket is used, the
top sheet can be folded back over the
FIGURE 21-25A Grasp the center of the end
blanket, making a cuff. This protects
seam on the pillowcase and turn the case back
the patient from the edge of the blanket. over the hand and lower arm.
26. Insert the pillow into the pillowcase as
follows:
a. Place hands in the clean pillowcase
and loosen the corners.
b. Use one hand to grasp the center of
the end seam on the outside. Turn
the case back over the hand and
lower arm (figure 21-25A).
c. Using the hand that is covered by the
case, grab the end of the pillow at the
center of the pillow (figure 21-25B).
d. Using your free hand, unfold the case
over the pillow (figure 21-25C).
e. Adjust the end corners of the pillow
into the corners of the case.
f. Adjust the pillowcase on the pillow. It
may be necessary to make a length-
wise pleat for a better fit.
CAUTION: Do not hold the pillow under
your chin or against your body. Rather, FIGURE 21-25B Using the pillow-covered
place it on the bed for support. hand, grab the end of the pillow.
PROCEDURE 21:3A
28. Lower the bed to its lowest position.
Replace all other equipment (bedside
table, call signal, chair, etc.).
29. Before leaving the area, check to make
sure it is neat and clean.
30. Wash hands.
31. Record or report that a closed bed was
made.
Practice
evaluation sheet for 21:3A, Making
a Closed Bed, to practice this
FIGURE 21-25C Unfold the pillowcase over for further action.
the pillow.
27. Place the pillow on the bed, with the
open end pointed away from the door.
NOTE: This position looks neater and listed on the evaluation sheet, your
allows fewer organisms from the hall to instructor will grade your performance.
enter the pillow.
PROCEDURE 21:3B
Making an Procedure
Occupied Bed 1. Assemble equipment.
Equipment and Supplies entering. Introduce yourself. Identify
Laundry hamper, cart, or bag; two large sheets the patient. Explain the procedure.
(or one large sheet and one fitted sheet); draw 3. Close the door and screen the unit for
sheet (if used); spread; pillow; pillowcase; privacy.
blanket (if needed); bath blanket; disposable
protective pads; pen or pencil
818 CHAPTER 21
PROCEDURE 21:3B
4. Wash hands.
CAUTION: Put on gloves and observe
standard precautions if linen on bed is
contaminated with blood, body fluids,
secretions, or excretions.
5. Arrange the clean linen on a chair in the
order in which the linen will be used.
6. Lock the wheels of the bed. Elevate the
bed to a comfortable working position.
7. Lower the headrest and footrest so that FIGURE 21-26A Fanfold the bottom sheet up
the bed is flat, if permissible. to and under the draw sheet in the center of the
NOTE: Make sure the patient can toler- bed.
ate this position before going on with 15. Place the clean bottom sheet on the bed
the procedure. right side up. Place the narrow hem even
8. Lower the siderail on the side where you with the foot of the bed. Center using
are working. the center fold. Fanfold the opposite
side close to patient.
CAUTION: Make sure the siderail on the
opposite side is elevated. CAUTION: Avoid injury. Use correct
body mechanics, including a broad base
9. Loosen the top bedclothes at the bot-
of support.
tom of the mattress. Remove the spread
and blanket. If they are to be reused, 16. Tuck in the clean bottom sheet at the
fold and place them over the chair. head of the bed. Make a mitered corner.
Working from the head to the foot of the
10. Replace the top sheet with a bath blan-
bed, tuck in the entire side.
ket. Have the patient hold the top edge
of the bath blanket, if able, while you NOTE: If a fitted sheet is used, it is posi-
slide the soiled top sheet out from top to tioned on the bed, with the contour cor-
bottom. Place the soiled sheet in the ners positioned at the head and foot of
linen hamper, cart, or bag. the mattress.
CAUTION: Avoid shaking the linen 17. Place the clean draw sheet on the bed.
because doing so spreads germs. Hold Center using the draw sheet’s center
the linen away from your body. fold. Fanfold the opposite half close to
the patient. Tuck the draw sheet firmly
11. Remove the pillow. If this makes the
under the mattress at the side (figure
patient uncomfortable, leave the pillow
21-26B).
under the patient’s head.
18. Turn the patient toward you. Caution
12. Assist the patient in turning to the oppo-
the patient that he or she will be turning
over the top of the fanfolded linen. Ele-
13. Fanfold the cotton draw sheet up to the vate the siderail.
patient’s body.
19. Go to the opposite side of the bed. Lower
14. Fanfold the bottom sheet up to and the siderail.
under the draw sheet (figure 21-26A).
20. Remove the soiled bottom sheet and
Make sure all of the sheets are as close
draw sheet. Place in the linen hamper,
to the patient as possible.
cart, or bag.
PROCEDURE 21:3B
from the top to the bottom of the bed
(figure 21-26D).
CAUTION: Avoid exposing the patient
during this procedure.
26. If a blanket is to be used, place it over
the top sheet.
27. Place the spread on top, right side up.
Center it on the bed.
28. Tuck the top sheet, blanket, and spread
into the bottom of the mattress. Make a
FIGURE 21-26B Tuck the clean bottom sheet mitered corner. Before tucking in the
and draw sheet firmly under the mattress. final fold, form a toe pleat by making a
3-inch fold in the top of the linen (figure
21. Pull the clean bottom sheet into place. 21-27). The fold should be made toward
Tuck it under the mattress at the head of the foot of the bed. Complete the
the bed. Make a mitered corner. mitered corner.
22. Pull gently to remove all wrinkles. Tuck

the side of the sheet under the mattress,
working from top to bottom.
23. Pull the clean draw sheet into place (fig-
ure 21-26C). Remove all wrinkles and
tuck it firmly under the side of the mat-
tress.
24. Assist the patient to turn on his or her
back in the center of the bed.
25. Place the top sheet, wrong side up, over
the bath blanket. Center using the FIGURE 21-26D After covering the patient
sheet’s center fold. Ask the patient to with a clean top sheet, remove the bath blanket.
hold the top edge of the clean sheet.
Remove the bath blanket by pulling it
FIGURE 21-26C Pull the clean draw sheet FIGURE 21-27 Make a toe pleat in the top
into place and tuck it under the side of the linen to provide more room for the patient’s feet
mattress. and toes.
820 CHAPTER 21
PROCEDURE 21:3B
NOTE: The toe pleat provides more 35. Dispose of dirty linen in the appropriate
room for the patient’s feet and toes and location. Properly replace all equipment.
prevents pressure on the toes from the
36. Wash hands.
sheets.
37. Report that an occupied bed was made
29. Raise the siderail and go to the opposite
side of the bed. Lower the siderail and
complete the top sheets on the opposite
form, for example, date, time, occupied
side of the bed.
bed made, and your signature and title.
30. Fold the top edge of the spread over and Note any unusual observations.
under the top of the blanket. Bring the
top sheet over the top of the spread and
blanket, and make a 6- to 8-inch cuff.
31. Insert the pillow into a clean pillowcase
as instructed in Procedure 21:3A.
Practice
32. Place the pillow on the bed, with the evaluation sheet for 21:3B, Making
open end away from the door. an Occupied Bed, to practice this
33. Position the patient comfortably in good
body alignment. have mastered this skill, sign the
34. Observe all checkpoints before leaving for further action.
the patient: place the call signal and
other supplies within easy reach of the
patient, lower the bed to its lowest level, Final Checkpoint Using the criteria
elevate the siderails (if necessary), and listed on the evaluation sheet, your
leave the area neat and clean. instructor will grade your performance.
PROCEDURE 21:3C
NOTE: For an ambulatory patient, the
Opening a Closed Bed bed is made as a closed bed and then
converted to an open bed.
Equipment and Supplies 3. Place the pillow on a chair or overbed
Closed bed with linen in place, pen or pencil table.
4. Go to the head of the bed and work from
Procedure its side. Fold the top edge of the spread
over and under the blanket. Fold the top
1. Wash hands. sheet down over the blanket and spread
2. Check the closed bed to be sure it was to form a cuff.
made correctly. Lock the wheels and 5. Face the foot of the bed. Hold the upper
elevate the height of the bed to a com- edge of the top layers of linen (spread,
fortable working position. blanket, and sheet) with both hands.
PROCEDURE 21:3C
6. Fanfold the linen into three even layers reach of the bed, lower the bed to its
down to the foot of the bed (figure lowest level, lock the bed wheels, cor-
21-28). rectly position all equipment, leave the
NOTE: The top of the fold should be fac-
ing the head of the bed. In this manner, 9. Wash hands.
the patient will be able to pull the top
10. Report that an open bed was made and/
covers up more readily after getting into
or record all required information on
the bed.
the patient’s chart or the agency form,
7. Place the pillow back at the head of the for example, date, time, open bed made,
bed. Make sure the open end is away and your signature and title.
from the door.
the area: place the call signal within easy
Practice
evaluation sheet for 21:3C, Opening
a Closed Bed, to practice this
for further action.

FIGURE 21-28 In an open bed, the top listed on the evaluation sheet, your
sheets are fanfolded to the foot of the bed. instructor will grade your performance.
PROCEDURE 21:3D
Placing a Bed Cradle entering. Introduce yourself. Identify
Equipment and Supplies 3. Close the door and screen the unit to
Laundry hamper, cart, or bag; bed cradle; two provide privacy.
large sheets (or one large sheet and one fitted 4. Wash hands.
sheet); draw sheet (if used); spread; pillow;
pillowcase; blanket (if needed); bath blanket; CAUTION: Wear gloves and observe
pen or pencil standard precautions if bed linen is con-
taminated with blood, body fluids,
Procedure secretions, or excretions.
822 CHAPTER 21
PROCEDURE 21:3D
5. Lock the bed wheels. Elevate the bed to clamps that attach to the mattress and/
a comfortable working height. Lower or bed frame. If no clamps are present,
the siderail on the side of the bed where roller gauze or straps can be attached to
you are working. the cradle and then fastened to the bed-
frame under the mattress.
CAUTION: Check the opposite siderail
to make sure it is raised and secured. NOTE: A restless or confused patient
may knock the cradle off of the bed. The
6. Use a bath blanket to cover the patient.
cradle should be clamped or tied in
Remove soiled top linen and place it in
place to prevent this.
the linen hamper, cart, or bag.
13. Place the top sheet, blanket, and spread
7. Turn the patient toward the opposite
over the top of the cradle and patient.
side of the bed.
Remove the bath blanket. Tuck in the
8. Loosen the bottom sheet and draw top sheets at the foot of the bed.
sheet, and fanfold them to the center of
14. Miter the corners and tuck them into
the bed.
place. A larger fold can be made near
9. Place the clean bottom sheet and draw the lower edge of the cradle to form a
sheets on the bed as described in Proce- neater mitered corner.
dure 21:3B, Making an Occupied Bed.
15. Make a cuff by folding the top sheet over
Finish changing bottom linen on both
the blanket and spread.
sides of the bed.
16. Insert the pillow into a clean pillowcase.
10. Position the patient in the center of the
Position the pillow on the bed, with the
bed and on his or her back.
open end away from the door.
11. Place the bed cradle into position (fig-
ure 21-29).
the patient: the patient is safe, comfort-
CAUTION: To prevent injury, make sure able, and in good body alignment; the
the cradle is not touching any part of the call signal and other supplies are within
patient’s skin. easy reach of the patient; the siderails
12. Tie or anchor the cradle to the bed as are elevated (if indicated); the bed is at
necessary. Many bed cradles have metal its lowest level; the area is neat and
clean.
18. Check placement of the bed cradle at
the end of the procedure and at inter-
vals afterward. Make sure it keeps the
bed linen away from the patient. Make
sure it is securely in place.
20. Wash hands.
21. Report that a bed with cradle was made
form, for example, date, time, bed with
FIGURE 21-29 A bed cradle supports the top cradle made, and your signature and
linen and prevents the linen from coming into title. Note any unusual observations.
contact with the patient’s legs and feet.
PROCEDURE 21:3D
Practice
Go to the workbook and use the evaluation sheet for 21:3D, Placing a Bed Cradle, to
practice this procedure. When you believe you have mastered this skill, sign the sheet and
give it to your instructor for further action.
Final Checkpoint Using the criteria listed on the evaluation sheet, your instructor will
grade your performance.
21:4 INFORMATION ♦ Partial bed bath: The health care worker

bathes some parts of the patient’s body. The
Administering Personal Hygiene term partial bath (PB) has two meanings, both
related to the patient’s ability to help. If the
Administering personal care and hygiene
patient is too weak to help, a partial bath
may be one of your responsibilities as a
means that only the face, arms, hands, back,
health care worker. Ill patients often depend on
and perineal area are bathed by the health
health care workers for all aspects of personal
care worker. If the patient is able to wash most
care. The health care worker must be sensitive to
of his or her body, a partial bath means that
the patient’s needs and respect the patient’s right
the health care worker completes the bath,
to privacy while personal care is administered.
usually bathing the patient’s legs and back. In
Personal hygiene usually includes bathing,
both types of partial baths, the health care
back care, perineal care, oral hygiene, hair care,
worker prepares the supplies needed by the
nail care, and shaving, when necessary. Such care
patient (figure 21-30).
promotes good habits of personal hygiene, pro-
vides comfort, and stimulates circulation. Pro- ♦ Tub bath or shower: Some patients are allowed
viding such care also gives the health worker an to take tub baths or showers. The health care
excellent opportunity to develop a good and car- worker helps as needed by providing towels
ing relationship with the patient. and supplies, preparing the tub or shower
area, and assisting the patient as much as the
situation demands.
TYPES OF BATHS ♦ Waterless bath: Some facilities are using pre-
packaged disposable cleansing cloths instead
Different types of baths are given to patients. The
of basins of water for baths (figure 21-31). The
type of bath depends on the patient’s condition
cleansing cloths contain a rinse-free cleanser
and ability to help.
and moisturizer, and are warmed in a micro-
♦ Complete bed bath (CBB): The health care wave (follow package instructions) or in a spe-
worker bathes all parts of the patient’s body cial warmer. Most packages contain from 8–10
and also provides oral hygiene, back care, hair cloths. Usually one cloth is used for the face,
care, nail care, and perineal care. A complete neck, and ears; one for each arm and each leg;
bath is usually given to the patient who is con- one for the chest and abdomen; one for the
fined to bed and is too weak or ill to bathe. perineum; and one for the back and buttocks.
824 CHAPTER 21
ORAL HYGIENE
Oral hygiene means care of the mouth and
teeth. Oral hygiene should be administered at
least three times a day. If the patient’s condition
requires frequent oral care, it should be adminis-
tered more often, usually at least every 2 hours.
Proper oral hygiene prevents disease and dental
caries, stimulates the appetite, and provides
comfort. In addition, it aids in the prevention of
halitosis (bad breath).
♦ Routine oral hygiene refers to regular, every-
day toothbrushing and flossing. Many times,
patients are able to provide their own care. In
such cases, the health care worker provides all
FIGURE 21-30 Position supplies conveniently of the necessary equipment and supplies. In
when assisting a patient with a partial bath. other cases, the worker helps the patient brush
and care for the teeth and mouth.
♦ Denture care is necessary when a patient has
dentures or artificial teeth. In such cases, the
health care worker must help clean the den-
tures. Patients may be sensitive about den-
tures. Therefore, it is important that the health
care worker provide privacy and reassure the
patient. Extreme care must also be taken to
prevent damage to the dentures.
♦ Special oral hygiene is usually provided for the
unconscious or semiconscious patient. Be-
cause many of these patients breathe through
their mouths, extra care must be taken to
clean all parts of the mouth. Special supplies
are used for this procedure.
HAIR CARE
Hair care is an important aspect of personal care
that is, unfortunately, frequently neglected.
Patients confined to bed often have tangles and
knots in their hair. Tangles or knots can be removed
FIGURE 21-31 Packages of cleansing cloths con- by combing a small section of hair at a time and
taining a rinse-free cleaner and moisturizer can be
working from the ends toward the scalp. Condi-
used to give a waterless bath. (Courtesy of Sage
Products, Inc.)
tioners can help prevent tangles. Braiding long
hair after the tangles are removed also helps
reduce the number of tangles and knots. Brushing
stimulates circulation to the scalp and helps pre-
The solution dries quickly on the skin, but a vent scalp disease. Brushing also removes dirt
towel can be used to gently remove excess and/or lint, and helps keep the hair shiny and
moisture. Extreme care must be taken to avoid attractive. It is also important to observe the con-
overheating the cloths. Read and follow man- dition of the hair and scalp. Signs of disease, red-
ufacturer’s instructions. ness, scaling, scalp irritation, or any other
conditions should be reported. Shampooing must ing. File toenails straight across. Learn and follow
be approved by the physician. Various types of dry your agency policy on nail care.
or fluid shampoos are available for patients con-
fined to bed. Read all instructions carefully before
using any of these products. Special devices are SHAVING
also available for use while giving a shampoo to a
patient confined to bed (figure 21-32). Shaving is a normal daily routine for most men. It
is important to provide this care when the patient
is unable to shave himself. Either regular or elec-
NAIL CARE tric razors may be used. The type used usually
depends on the patient’s personal preference.
Nail care is another often-neglected area in the Correct technique must be used to prevent injury
personal care of the patient. Nails harbor dirt, to the patient. Female patients usually appreciate
which can lead to infection and disease. In addi- shaving of the legs and underarms. Be sure you
tion, rough or sharp nails can cause injury. It is have specific orders from the physician or your
important that nail care be included as a part of immediate supervisor before shaving any patient.
the daily personal care provided to the patient. Shaving may be prohibited or special precautions
However, nails should never be cut unless you may be required for patients on anticoagulants,
receive specific orders to do so from the physi- or medications that prevent the blood from
cian or your immediate supervisor. Cutting of the clotting.
nails may cause injury. In some facilities, only
licensed or advanced practice personnel are
allowed to cut fingernails. If you are permitted to BACK RUB
cur fingernails, use nail clippers, not scissors, and
clip the nails straight across. Never cut below the Unless contraindicated by the patient’s condi-
tips of the fingers. Clip slowly and carefully to tion, a back rub is given as part of the daily bath.
avoid accidentally damaging the skin around the It can also be given at other times during the day
nail. Then file the nails straight across to remove and should be done at least once every 8 hours
rough edges. Never cut toenails because injuries for a patient confined to bed. A good back rub
to the feet are prone to infection and slow heal- takes at least 4–7 minutes and stimulates circula-
tion, prevents pressure ulcers, and leads to relax-
ation and comfort. It is important that the health
care worker’s nails be short to prevent injury.
CHANGING A GOWN
OR CLOTHING
Changing a patient’s gown or pajamas is also
important. Most patients prefer to wear their own
gowns or pajamas. However, hospital gowns are
frequently used on very ill patients or on patients
with limited movement. These gown usually open
down the back and are easier to position and
remove. If the patient has a weak or injured arm,
or if an intravenous solution is being infused in
one arm, the gown or pajama top must be posi-
tioned with care. Usually, the sleeve of the soiled
gown or pajama top is removed from the unin-
jured or untreated arm first. This allows more
FIGURE 21-32 Special devices are available for freedom of movement while removing the sleeve
use when shampooing the hair of a patient confined from the injured or treated arm. Likewise, the
to bed. sleeve of the clean gown or pajama top is placed
826 CHAPTER 21
on the affected arm first and then is placed on the ♦ Swelling, or edema: This can indicate poor cir-
unaffected arm. It is sometimes necessary to culation or disease and should be reported
leave one arm out of the gown and place the immediately. Pay particular attention to the
sleeve on the unaffected arm only. Some agencies hands, feet, ankles, and toes.
have gowns with openings at the shoulders. Such
a gown can be placed over a treated arm and then
♦ Other signs of distress: Difficult breathing
(dyspnea), dizziness (vertigo), unusual weak-
closed with snaps, ties, or Velcro strips at the
ness, excessive perspiration (diaphoresis),
shoulder area. In home care, gowns or pajama
extreme pallor, or abnormal drowsiness or
tops can be opened at the arm seam for easy
sluggishness (lethargy) should be reported
application. Velcro strips or ties can then be
immediately.
applied so that the gown or pajama top can be
closed after being put on the patient. In long- When administering personal hygiene,
term care facilities, most residents wear regular standard precautions (described in Chapter
clothing during the day. It is important to help 14:4) must be observed at all times. Hands must
the resident as needed in choosing and dressing be washed frequently, and gloves must be worn
in appropriate clothing. If a resident has difficulty when contact with blood, body fluids, secretions,
moving one side or is paralyzed, always put the or excretions is likely. A gown must be worn if
clothing on the affected side first and remove it contamination of a uniform or clothing is likely. A
from the affected side last. mask and protective eyewear, or a face shield,
must be worn if droplets of blood or body fluids
are present, such as when a patient is coughing
SUMMARY excessively. Health care workers with cuts, sores,
or dermatitis on their hands must wear gloves for
When administering personal hygiene, it is all patient contact. Preventing the spread of infec-
important that the health care worker be alert for tion is a major responsibility of the health care
any signs that might be unusual. When perform- provider.
ing any personal hygiene procedure, watch for Always be sensitive to the patient’s feelings
and report any unusual observations, including and respect the patient’s rights. Knock on
the following: the door and pause before entering a patient’s or
♦ Sores, cuts, injuries: Any noted on the skin, resident’s room. Provide privacy during proce-
mouth, or scalp must be reported. dures by closing the door and screening the unit.
Avoid exposing the patient when administering
♦ Rashes: Any type of rash should be reported. personal hygiene. Explain all procedures and
Many times, a rash is the first sign of an aller-
reassure the patient as needed. Observe profes-
gic reaction to a medication.
sional ethics at all times.
♦ Color: Any unusual color should be noted.
Redness (erythema) of the skin is often the
first sign of a pressure sore, or decubitus ulcer.
A blue color (cyanosis) is a sign of poor circu- STUDENT: Go to the workbook and complete
lation. A yellow color (jaundice) is a sign of the assignment sheet for 21:4, Administering Per-
liver disease, bile obstruction, or destruction sonal Hygiene. Then return and continue with the
of red blood cells. procedures.
PROCEDURE 21:4A
Providing Routine Oral
Hygiene
Toothbrush, toothpaste or powder, mouth-
wash solution (if used) in cup, cup of water,
straw, emesis basin, bath towel, tissues, den-
tal floss, plastic bag or plastic-lined waste
can, disposable gloves, pen or pencil
Procedure
1. Obtain proper authorization and assem-
ble equipment.
FIGURE 21-33A Position all supplies in a
2. Knock on the door and pause before convenient location when assisting a patient
entering. Introduce yourself. Identify with routine oral hygiene.
3. Wash hands. Put on gloves. If spraying 7. If the patient cannot brush, brush the
or splashing of oral fluids is possible, patient’s teeth. Carefully insert the brush
wear a face mask and eye protection. into the patient’s mouth. Start at the rear
of the upper teeth. Place the brush at a
CAUTION: Observe standard precau- slight angle to the gum, rotate gently,
tions when contamination by body flu- and then use a slight vibrating motion
ids is possible. to thoroughly clean all of the upper
4. Position the patient comfortably. Close teeth. Repeat this process on the lower
the door and screen the unit to provide teeth.
privacy. Raise the head of the bed, if per- 8. Give the patient water from the cup to
mitted. Elevate the bed to a comfortable rinse the mouth. Provide a straw, if
working height. Lower the siderail on needed.
the side where you are working. Position
the overbed table containing all equip- 9. Hold the emesis basin under the
ment in a convenient location (figure patient’s chin. Instruct the patient to
21-33A). expel the mouth secretions into the
basin (figure 21-33B).
NOTE: If the patient can brush his or her
own teeth, the overbed table is usually 10. Repeat steps 8 and 9, as necessary.
positioned over the patient’s lap. 11. Offer tissues to allow the patient to wipe
5. Place the bath towel on the bedclothes the mouth and chin. Discard tissues in
and over the patient’s shoulders. the plastic bag.
NOTE: A disposable bed protector can 12. Provide dental floss. Allow the patient to
also be used to drape the patient. floss the teeth. Assist as needed. If the
patient is not able to floss, obtain a piece
6. Put water on the toothbrush. Add tooth- of floss about 12–18 inches long. Gently
paste. Give the brush to the patient. insert the floss between the teeth. Curve
NOTE: Before adding the toothpaste, the floss into a C-shape. Use a gentle
ask how much the patient uses. up-and-down motion to clean the sides
828 CHAPTER 21
PROCEDURE 21:4A
lower the bed to its lowest level, and
leave the area neat and clean.
16. Rinse the toothbrush thoroughly. Use
cool water and towels to clean the eme-
sis basin. Properly replace all equip-
ment.
17. Remove gloves. Remove mask and eye
protection, if worn. Wash hands.
18. Report that routine oral hygiene was
given to the patient and/or record all
required information on the patient’s
FIGURE 21-33B Instruct the patient to chart or the agency form, for example,
expectorate (spit) into the emesis basin. date, time, oral hygiene given, and your
signature and title. Note any unusual
observations.
of the teeth. Repeat for both sides of

every tooth.
13. Provide mouthwash, if desired by the
patient. Mouthwash is sometimes
Practice
diluted to a proportion of half mouth-
wash to half water. Use the emesis basin
and tissues, as necessary to allow the Providing Routine Oral Hygiene, to
patient to expectorate the mouthwash. practice this procedure. When you
14. Remove all equipment. Position the sign the sheet and give it to your
patient comfortably. Be sure the patient instructor for further action.
is in good body alignment.
the patient: elevate the siderails (if indi- Final Checkpoint Using the criteria
cated), place the call signal and other listed on the evaluation sheet, your
supplies within easy reach of the patient, instructor will grade your performance.
PROCEDURE 21:4B
Cleaning Dentures Procedure
Equipment and Supplies ble equipment.
Toothbrush and toothpaste or denture brush 2. Knock on the door and pause before
and denture cleaner, denture cup, tissues, entering. Introduce yourself. Identify
cup with mouthwash (if used), straw, applica- the patient. Explain the procedure.
tors, bath towel, paper towels, emesis basin,
NOTE: The patient may be sensitive
plastic bag or plastic-lined waste can, dispos-
about dentures. Provide privacy and
able gloves, pen or pencil
reassurance.
PROCEDURE 21:4B
3. Close the door and screen the unit for NOTE: This provides a protective cush-
privacy. ion for the dentures should they be
dropped.
9. Put toothpaste or powder on the tooth-
brush. Place the dentures in the palm of
tions when contamination by body flu-
one hand. Holding them under a gentle
ids is possible.
stream of cool or lukewarm water, brush
5. Elevate the bed to a comfortable work- all surfaces thoroughly (figure 21-34B).
ing height. Raise the head of the bed, if
CAUTION: Do not use hot water. This
permitted. Lower the siderail on the side
can cause breakage.
where you are working.
NOTE: Clean all parts of the dentures,
6. Offer tissues to the patient. Ask the
not just the teeth.
patient to remove the dentures. If the
patient is unable to do so, use tissues or NOTE: Dentures can be soaked in a
a gauze sponge to grasp the dentures solution containing a cleansing tablet
between your thumb and index finger prior to brushing.
(figure 21-34A). Gently apply downward
10. Rinse dentures thoroughly in cool
and forward pressure to loosen and
water.
remove the top denture. Remove the
lower denture by grasping it with your CAUTION: Do not use very cold water.
thumb and forefinger and turning it This can also cause breakage.
slightly to lift it out of the mouth. 11. Put clean, cool water in the denture cup.
CAUTION: Never force dentures loose. Place the cleaned dentures in the cup.
They can break. 12. Return to the patient’s bedside. Lower
7. Carefully place the dentures in a den- the siderail on the side where you will be
ture cup. Raise the siderails for patient working.
safety. Carry the dentures to the sink. 13. Help the patient to rinse the mouth with
8. Line the sink with paper towels. cool water and/or mouthwash. Use the
FIGURE 21-34A Use tissues or a gauze

sponge to grasp the dentures and ease them
down and forward to remove them from the FIGURE 21-34B Hold the dentures securely
mouth. while brushing all surfaces.
830 CHAPTER 21
PROCEDURE 21:4B
emesis basin and tissues. Place used tissues, water, and supplies within easy
sues in the plastic bag. reach of the patient; clean and replace
all equipment; and leave the area neat
NOTE: Some patients want to brush
and clean.
their gums with a soft toothbrush or
applicator moistened with mouthwash 16. Remove gloves. Wash hands thoroughly.
before inserting clean dentures. Assist
17. Report that denture care was given and/
the patient, as necessary.
14. Hand the dentures to the patient. Help patient’s chart or the agency form, for
the patient insert the dentures, as example, date, time, dentures cleaned,
needed. The upper denture is inserted and your signature and title. Note any
first. unusual observations.
NOTE: If the patient desires adhesive,
line the palates of the dentures with
denture adhesive.
NOTE: If dentures are not immediately Practice
returned to the patient, they should be Go to the workbook and use the
stored inside the denture cup and in a evaluation sheet for 21:4B, Cleaning
safe area (such as a drawer), and labeled Dentures, to practice this procedure.
with the patient’s name and room num- When you believe you have
ber. At times, a denture cleansing or mastered this skill, sign the sheet
soaking tablet is placed in the water and give it to your instructor for
when dentures are stored. further action.
rect body alignment; elevate the side- Final Checkpoint Using the criteria
rails (if necessary); lower the bed to its listed on the evaluation sheet, your
lowest level; place the call signal, tis- instructor will grade your performance.
PROCEDURE 21:4C
Giving Special Procedure
Mouth Care 1. Check physician’s orders or obtain
authorization from your immediate
Equipment and Supplies supervisor.
Glycerine and lemon juice prepared swabs, 2. Assemble equipment.

tissues, emesis basin, bath towel or underpad 3. Knock on the door and pause before
(protective pad), cotton-tipped applicator entering. Introduce yourself. Identify
sticks, water-soluble lubricant for lips, mouth the patient by checking the wristband
solution as ordered (optional), plastic bag or and addressing the patient by name.
plastic-lined waste can, disposable gloves, Explain the procedure.
pen or pencil
NOTE: Semiconscious or unconscious
patients can sometimes hear.
PROCEDURE 21:4C
4. Close the door and screen the unit for
privacy.
tions when contamination by body flu-
ids is possible.
6. Elevate the bed to a comfortable work-
ing height. Raise the head of the bed if
permissible. Lower the siderail on the
side where you are working.
7. Turn the patient’s head to the side
toward you. Place the bath towel or
underpad under the patient’s head and
chin.
8. Open the package of mouth swabs con-
taining lemon and glycerine.
NOTE: Toothettes are a common brand
name of mouth swabs.
NOTE: Some prepared swabs contain
hydrogen peroxide in place of the lemon
and glycerine.
9. Use the prepared swab to cleanse all FIGURE 21-35 Use the prepared swab to
parts of the patient’s mouth (figure cleanse all parts of the patient’s mouth while
21-35). Cleanse the teeth, gums, tongue, providing special oral hygiene.
and roof of the mouth thoroughly. Work
from the gums to the cutting edges of 12. Use the cotton-tipped applicator sticks
the teeth. Use a gentle motion. to apply water-soluble lubricant lightly
10. Discard used swabs in the plastic bag. to the tongue and lips.
Use fresh swabs until the entire mouth NOTE: This keeps the tissues soft and
is clean. moist.
11. If the patient is able to help, have him or 13. Reposition the patient in correct body
her rinse the mouth with mouthwash, if alignment.
allowed. Then follow with a freshwater
rinse. If the patient is unconscious, use 14. Replace all equipment used. A tray with
clean applicators moistened with clear supplies for special mouth care is some-
water to rinse the patient’s mouth. Use a times kept at the bedside. If so, restock
soft towel to dry the area around the supplies on the tray so it is always ready
mouth. for use.
CAUTION: Never give an unconscious 15. Observe all checkpoints before leaving
or semiconscious patient mouthwash the patient: elevate the siderails (if indi-
or any other liquids. cated), place the call signal within easy
reach of the patient, lower the bed to its
lowest level, and leave the area neat and
clean.
832 CHAPTER 21
PROCEDURE 21:4C
17. Report that special mouth care was
given and/or record all required infor-
Practice
agency form; for example, date; time; evaluation sheet for 21:4C, Giving
special mouth care given, lips appear Special Mouth Care, to practice this
dry and chapped; and your signature procedure. When you believe you
and title. Immediately report any prob-
lems noted, including sores, irritated
areas in the mouth, bleeding gums,
for further action.
and/or cuts.

PROCEDURE 21:4D
Administering Daily ing height. Raise the head of the bed, if
Hair Care permissible. Lower the siderail on the
side where you are working.
Equipment and Supplies 6. Cover the pillow with the towel.
Comb and/or brush, towel, alcohol or baby 7. Ask the patient to move to the side of
oils, pen or pencil the bed nearest you. Assist as neces-
sary.
Procedure CAUTION: Use proper body mechanics,
including a broad base of support. Bend
1. Obtain proper authorization and assem- from hips.
ble equipment.
8. Part or section the hair. Start at one side
2. Knock on the door and pause before and work around to the other side.
the patient. Explain the procedure. 9. Comb or brush the hair thoroughly.
Keep the fingers of your hand between
3. Close the door and screen the unit to the scalp and comb whenever possible.
provide privacy. If the hair is not tangled or knotted,
4. Wash hands. begin at the scalp and work toward the
ends of the hair.
standard precautions if the scalp has NOTE: This prevents pulling and
open sores or infected areas. Some decreases discomfort.
health care facilities require that gloves 10. Do each section completely. To do the
be worn while providing hair care. Fol- back of the head, turn the patient or lift
low agency policy. the head slightly.
PROCEDURE 21:4D
11. If the hair is very tangled or knotted, do that they will not injure the scalp. Avoid
the following: the use of rubber bands whenever pos-
sible because they can break and dam-
a. Spray a small amount of water on the
age the hair.
hair. Comb or brush the hair gently
starting at the ends and working 13. Throughout the entire procedure,
toward the scalp to remove the knots closely observe the condition of the
and tangles. If the patient has condi- scalp and hair. Report any abnormal
tioner, spraying a small amount of conditions immediately.
conditioner on the hair may also help
remove the knots and tangles.
b. For very dry hair, put a very small rect body alignment, elevate the side-
amount of baby oil on your hands rails (if indicated), lower the bed to its
and rub it into the hair. Then comb lowest level, place the call signal and
or brush gently. Start at the ends of supplies within easy reach of the
the hair and work toward the scalp. patient.
c. For very oily hair, put a small amount 15. Clean and replace all equipment used.
of alcohol on your hands and apply it It is sometimes necessary to remove hair
to the hair. Comb or brush. from the brush and comb. Wash the
comb and brush in a mild, soapy solu-
CAUTION: Be careful not to get alcohol
tion. Rinse thoroughly. Leave the area
near the patient’s eyes.
neat and clean.
12. When all areas of the hair have been
16. Wash hands.
brushed or combed, arrange the hair
attractively according to the patient’s 17. Report that hair care was given and/or
preference (figure 21-36). After obtain- record all required information on the
ing the patient’s permission, braid long patient’s chart or the agency form, for
hair to prevent tangling. example, date, time, hair combed and
braided, and your signature and title.
NOTE: Hair bands or hairpins can be
Note any unusual observations.
used to hold the hair in place. Take care
Practice
Administering Daily Hair Care, to

FIGURE 21-36 Arrange the hair attractively listed on the evaluation sheet, your
after brushing or combing it. instructor will grade your performance.
834 CHAPTER 21
PROCEDURE 21:4E
8. Use the slanted or blunt edge of the
Providing Nail Care orange stick to clean dirt out of the nail-
beds under the nails (figure 21-37). A
Equipment and Supplies nail brush can also be used to clean the
nails. Carefully check the nails and sur-
Orange stick, emery board, nail clippers (if rounding skin while cleaning the nails.
permitted), water and mild detergent in
basin, towel, plastic bag, pen or pencil CAUTION: Using the pointed edge can
result in a puncture wound. Using a
CAUTION: In some facilities, only metal instrument such as a nail file can
licensed or advance practice personnel roughen the nail, causing it to harbor
are permitted to cut fingernails. In addi- dirt.
tion, cutting nails may be prohibited for
some patients, such as patients with NOTE: If any redness, excessive dryness,
diabetes. It is important to learn and fol- or cracking of the skin is noted, report
low agency policy regarding nail care. this to your supervisor immediately.
9. Use the emery board to file the nails and
Procedure shorten them. Use short strokes. Work
from the side of the nail to the top of the
1. Check physician’s orders or obtain nail. Repeat for the opposite side.
supervisor. NOTE: Do not use a back-and-forth
motion. Such a motion can split the
2. Assemble equipment. nails.
3. Knock on the door and pause before 10. If the fingernails are very long, and you
entering. Introduce yourself. Identify are allowed to cut them, use nail clip-
the patient. Explain the procedure. pers to cut the nails straight across. Be
4. Close the door and screen the unit to careful not to injure the skin around the
provide privacy. nail. Never cut toenails. File them
straight across.
5. Wash hands.
CAUTION: Do not use scissors. They can
CAUTION: Wear gloves and observe cut the patient.
standard precautions if any contact with
nonintact skin or body fluids is likely.
Some health care facilities require that
gloves be worn while providing nail care.
Follow agency policy.
ing height. Lower the siderail on the side
7. Clean the nails by soaking them for 5–10
minutes in a solution of mild detergent
and water at a temperature of 105°–
110°F (40.6°–43.3°C). This loosens the
dirt in the nailbeds.
NOTE: Oil is sometimes used in place of FIGURE 21-37 After soaking the nails, use
detergent. the blunt edge of an orange stick to remove any
dirt from under the nails.
PROCEDURE 21:4E
11. When the nails are the correct length, 16. Clean and properly replace all equip-
use the smooth side of the emery board ment used.
to eliminate rough edges. Make sure
17. Wash hands.
that the nails are filed straight across.
18. Report that nail care has been given
CAUTION: Pointed nails may cause
injuries.
on patient’s chart or the agency form,
12. When the nails have been cleaned and for example, date, time, nail care given
filed short, apply lotion or another to fingers and toes, and your signature
emollient, such as cold cream. This and title. Report any observations that
helps keep the nails and cuticles in good may signify problems.
condition.
NOTE: Nail care can be carried out for
fingernails and toenails.
13. Apply lotion to the hands and/or feet. Practice
Do not apply lotion between the toes Go to the workbook and use the
because this promotes the growth of evaluation sheet for 21:4E,
fungus. Providing Nail Care, to practice this
14. Position the patient in correct body
alignment. have mastered this skill, sign the
15. Observe all checkpoints before leaving for further action.
the patient: elevate the siderails (if indi-
cated); place the call signal, water, and
tissues within easy reach of the patient; Final Checkpoint Using the criteria
lower the bed to its lowest level; leave listed on the evaluation sheet, your
the area neat and clean. instructor will grade your performance.
PROCEDURE 21:4F
backrub would be too stimulating and
Giving a Backrub affect the circulation. Other patients
with burns, back injuries, back surger-
Equipment and Supplies ies, and similar conditions may not be
able to tolerate a backrub.
Lotion, bath towel, washcloth, soap and
water, disposable gloves (if needed), basin, 2. Assemble equipment.
pen or pencil 3. Knock on the door and pause before
Procedure the patient. Explain the procedure.
1. Obtain authorization from your imme- 4. Close the door and screen the unit to
diate supervisor or check physician’s provide privacy.
orders. 5. Wash hands. Put on gloves if contact
NOTE: Some patients cannot receive a with nonintact skin is possible.
backrub because of heart disease. A
836 CHAPTER 21
PROCEDURE 21:4F
6. Elevate the bed to a comfortable work- (figure 21-38). Use firm pressure on the
ing height. Lower the siderail on the side upward strokes and gentle pressure on
where you are working. the downward strokes. Repeat this step
four times.
7. Position the patient. The patient can lie
on the abdomen (prone), or if this is not NOTE: See figure 21-39A.
comfortable, on his or her side, facing
CAUTION: Long nails may scratch the
away from you.
patient. File your nails short before giv-
8. Place a bath towel lengthwise next to ing a backrub.
the patient’s body.
CAUTION: Use proper body mechanics.
9. Fill the basin with water at a tempera- Get close to the patient by bending at
ture of 105–110°F (40.6–43.3°C). Wash your hips and knees, and keep your back
the patient’s back thoroughly. Rinse and straight. Position your feet to provide a
dry the back. broad base of support.
NOTE: If the patient has had a bed bath,
this step is not necessary, because the
back has already been washed.
NOTE: Be alert for any abnormal condi-
tion of the skin. Note any red areas, rash,
sores, or cuts. Pay particular attention
to bony parts.
10. Rub a small amount of lotion into your
hands.
NOTE: This warms the solution slightly.
The container of lotion can also be
placed in a basin of warm water prior to
use.
11. Begin at the base of the spine. Rub up
the center of the back to the neck,
around the shoulders, and down the
sides of the back. Rub down over the
buttocks, around, and circle back to FIGURE 21-38 Use long, smooth strokes and
starting point. Use long, soothing strokes firm pressure when giving a backrub.
A B C D E
FIGURE 21-39 Motions for a backrub.

PROCEDURE 21:4F
12. Repeat the long, upward strokes, but on 19. Observe all checkpoints before leaving
the downward strokes, use a circular the patient: elevate the siderails (if indi-
motion. Pay particular attention to bony cated), lower the bed to its lowest level,
prominences. Repeat this motion four and place the call signal, water, and tis-
times. sues within easy reach of patient.
NOTE: See figure 21-39B. 20. Clean and replace all equipment. Leave
the area neat and clean.
CAUTION: Take care not to rub skin tags
as this might cause them to bleed. Also 21. Remove gloves if worn. Wash hands.
avoid massaging directly over reddened
22. Report that a backrub was given and/or
areas. Massage around these areas.
record all required information on
Report the presence of these areas to
patient’s chart or the agency form (for
your supervisor immediately.
example, date, time, back massage
13. Repeat the long, upward strokes, but on given, patient states he feels very
the downward strokes, use very small relaxed); and your signature and title.
circular motions. Use the palm of your Report any abnormal observations
hand to apply firm pressure. Pay partic- immediately.
ular attention to the bony prominences.
Do this motion one time.
NOTE: See figure 21-39C.
14. Repeat the long, soothing strokes used
initially. Do this for 3–5 minutes. Practice
NOTE: See figure 21-39D. Go to the workbook and complete
the evaluation sheet for 21:4F,
15. End the backrub with up-and-down Giving a Backrub, to practice this
motions over the entire back. Do this for procedure. When you believe you
1–2 minutes. This provides relaxation have mastered this skill, sign the
after stimulation.
NOTE: See figure 21-39E. for further action.
16. Dry the back thoroughly with the towel.
17. Straighten the bed linen. Change the
patient’s gown, if necessary.
18. Position the patient in good body align- listed on the evaluation sheet, your
ment. instructor will grade your performance.
30216_21_Ch21_779-929.indd 837 1/16/08 9:19:55 PM

838 CHAPTER 21
PROCEDURE 21:4G
8. Fill the basin with water at a tempera-
Shaving a Patient ture of 105–110°F (40.6–43.3°C). Use the
washcloth to moisten the face.
Equipment and Supplies 9. Apply lather. Put it on your fingers first
Razor with blade, shaving lather, gauze pad, and then apply it to the patient’s cheek.
basin with water, towel, washcloth, mirror, NOTE: It is usually best to do one area of
electric razor (for some patients), aftershave the face at a time.
lotion (optional), disposable gloves, sharps
10. Start in front of the ear. Hold the skin
container, pen or pencil
taut (stretched tightly) to prevent cuts
(figure 21-40A). Bring the razor down
Procedure over the cheek and toward the chin.
1. Obtain proper authorization. CAUTION: Always shave in the direc-
tion of hair growth.
CAUTION: If the patient is taking anti-
coagulants to prevent blood clots, shav- 11. Rinse the razor after each stroke. Repeat
ing may be prohibited or restricted to until the lather is removed and the area
the use of an electric razor. Always check is shaved.
with your immediate supervisor to con- 12. Repeat steps 9 to 11 for the opposite
firm whether a patient is on anticoagu- cheek, the chin and neck area, and
lants before shaving a patient. under the nose. When shaving the chin
2. Assemble equipment. Examine the and under the nose, instruct the patient
razor blade closely. Make sure there are to hold the skin taut. Use firm, short
no nicks or damaged edges. Carefully strokes. Rinse the razor frequently.
rub the razor blade over a folded gauze CAUTION: If the skin is accidentally
pad to check for damage. nicked, use a gauze pad to apply pres-
3. Knock on the door and pause before sure directly over the area. Then apply
entering. Introduce yourself. Identify an antiseptic or follow the policy of your
the patient. Explain the procedure. agency. Be sure to report the incident to
your immediate supervisor.
4. Close the door and screen the unit to
provide privacy.
5. Wash hands. Put on gloves if you are
using a safety razor.
tions. A safety razor can nick the skin
and cause bleeding.
ing height. Raise the head of the bed.
Lower the siderail on the side where you
are working. Put the patient in a com-
fortable position. Arrange all needed
equipment on the overbed table.
NOTE: Allow the patient to help as much
as possible. FIGURE 21-40A Hold the skin taut and shave
7. Place a towel over the patient’s chest in the direction of hair growth while shaving the
and near the patient’s shoulders. patient.
PROCEDURE 21:4G
tions when controlling bleeding.
13. Wash and thoroughly dry the face and
neck.
14. Apply aftershave lotion, if the patient
desires.
15. To use an electric razor, read the instruc-
tions that come with the razor.
a. Some patients prefer dry skin when
using an electric razor. Others prefer
to use a preshave lotion.
b. Hold the skin taut before using the
razor.
FIGURE 21-40B Discard the disposable
c. Some razors require short, circular
razor in a sharps container.
strokes. Others require short strokes
in the direction of hair growth. title. Report any observations that may
d. Shave all areas of the face. signify problems.
e. Wash and dry the face thoroughly NOTE: Female patients sometimes want
when done. facial, underarm, and/or leg hair shaved.
f. Apply aftershave lotion, if desired. Obtain proper authorization before
doing any of these procedures. Follow
g. Clean the razor thoroughly after use. the same steps: check the razor, moisten
Use a small brush (which usually the area, apply lather or a soapy solu-
comes with the razor) to clean out all tion, hold the skin taut, shave in the
the hair. direction of hair growth, rinse the area,
16. Observe all checkpoints before leaving do small sections at a time, and finish by
the patient: position the patient in cor- thoroughly washing and drying the
rect body alignment, elevate the side- areas shaved.
rails (if indicated), lower the bed to its
lowest level, and place the call signal
and supplies within easy reach of the
patient.
17. Clean and replace all equipment used. Practice
Wash the safety razor thoroughly. Dis- Go to the workbook and use the
card the blade in a puncture-resistant evaluation sheet for 21:4G, Shaving
sharps container. If a disposable razor a Patient, to practice this procedure.
was used, discard the entire razor in the When you believe you have
sharps container (figure 21-40B). mastered this skill, sign the sheet
further action.
19. Report that the patient was shaved and/
the patient’s chart or the agency form,
for example, date, time, shaved with
electric razor, and your signature and
840 CHAPTER 21
PROCEDURE 21:4H
essary exposure by using the towel or
Changing a Patient’s bath blanket, as necessary.
Gown or Pajamas c. If the patient is wearing pajamas, first
untie or unbutton the pants at the
Equipment and Supplies waist. Gently ease the pants down
over the legs and feet. Use the towel
Gown or pajamas; towel or bath blanket; linen
or bath blanket to drape the patient.
hamper, cart, or bag; disposable gloves (if
Avoid exposing the patient. Unbut-
needed), pen or pencil
ton the pajama top.
Procedure 7. Take off the soiled clothing, one sleeve
at a time. Gently grasp the edge of the
1. Obtain proper authorization and assem- sleeve near the shoulder. Ease the arm
ble equipment. out. Do the far arm first. If the patient
has an affected arm (injured, paralyzed,
weak, etc.) or is receiving an intravenous
(IV) infusion, remove the sleeve from
the unaffected arm first and from the
the patient.
affected arm or arm with the IV second.
3. Close the door and screen the unit to Place the soiled clothing on a chair.
provide privacy.
NOTE: If an IV is in place, ease the sleeve
4. Wash hands. If necessary, put on gloves. off of the upper arm, taking care not to
CAUTION: Wear gloves and observe disturb the infusion site, where the nee-
standard precautions if the gown is con- dle is inserted. Then gently ease the
taminated by blood, body fluids, secre- sleeve over the tubing by keeping your
tions, or excretions, such as drainage hand and arm in the sleeve holding the
from an incision. solution bottle above the infusion site,
and passing the container through the
5. Elevate the bed to a comfortable work- sleeve (figure 21-41A–C).
where you are working. NOTE: Many facilities use gowns that
open at the shoulder when a patient has
NOTE: It is easier to change the patient’s an IV. The gown is positioned over the
clothing if you first fold the bed covers shoulder and closed with snaps, ties, or
to the foot of the bed and cover the Velcro strips.
patient with a bath blanket.
8. Unfold the clean gown or pajama top
6. Loosen the patient’s bedclothes: and place it over the patient.
a. If the patient is wearing a hospital 9. Put the patient’s arms into the sleeves
gown, untie the tapes by having the one at a time. Gather the sleeve of the
patient turn on his or her side or by gown or pajama top into your hands.
reaching under the neck. Then gently Then put your arm through the sleeve,
pull out any part of the gown that is take the patient’s hand in yours, and slip
under the patient. the sleeve up the patient’s wrist and arm
b. If the patient is wearing a gown of her and to the shoulder.
own, loosen any buttons or ties. Gen- NOTE: If one arm is affected or has an
tly ease the gown upward from the IV, do this arm first. This places less
hemline to the neck. Prevent unnec- strain on the arm. For an IV, pass the
PROCEDURE 21:4H
FIGURE 21-41A After FIGURE 21-41B Ease the FIGURE 21-41C Keeping the
removing the gown from the gown over the IV tubing, taking IV container above the level of
unaffected arm, gather the care to prevent displacement of the infusion site, pass the IV
gown together on the arm with the tubing. container through the arm of the
the IV infusion site. gown.
solution container and tubing through towel or bath blanket to drape the
the sleeve first. Keep the solution con- patient.
tainer above the level of the infusion site
12. If the patient is wearing pajamas, put on
at all times.
the pants after the pajama top. Gently
CAUTION: Sometimes, a sleeve cannot ease the pants over the feet and up the
be placed because of an IV infusion legs. Adjust them into position at the
machine, bulky dressing, or other simi- waist. Use the towel or bath blanket to
lar problem. If this is the case, leave the cover the patient during this procedure.
sleeve off of the one arm, or use a gown Tie or button the pants. Make sure the
that opens at the shoulders. pants are smooth and free from wrinkles
or folds.
10. Pull the body of the gown down over the
patient or position the pajama top cor- 13. Observe all checkpoints before leaving
rectly. Make sure that the gown or top is the patient: position the patient com-
smooth and free from wrinkles or folds. fortably and in good body alignment;
elevate the siderails (if indicated); place
11. Tie the tapes or ties on the gown, or but-
the call signal, water, and supplies
ton the buttons on the pajama top. Make
within easy reach of the patient; lower
sure that the tied knot is not on a bony
the bed to its lowest level; and leave the
prominence.
CAUTION: Knots or wrinkles can lead to
14. Place a soiled hospital gown in the laun-
pressure ulcers.
dry hamper or bag. Place a soiled per-
NOTE: Avoid exposing the patient dur- sonal gown or pajamas in a drawer, the
ing the procedure. Continue to use the
842 CHAPTER 21
PROCEDURE 21:4H
closet, or other location specified by the
patient.
CAUTION: If the gown is contaminated
with blood or body fluids, follow agency
Practice
policy for handling contaminated evaluation sheet for 21:4H,
linen. Changing a Patient’s Gown or
NOTE: In long-term care facilities, the Pajamas, to practice this procedure.
patient’s soiled clothing is usually When you believe you have
washed by the facility. Make sure the mastered this skill, sign the sheet
clothing is labeled with the patient’s and give it to your instructor for
name and place it in the proper laundry further action.
hamper or bag.
15. Remove gloves, if worn. Wash hands
thoroughly.
16. Report that the patient’s gown has been
changed and/or record all required
agency form, for example, date, time,
pajamas changed, and your signature Final Checkpoint Using the criteria
and title. Report any observations that listed on the evaluation sheet, your
may signify problems. instructor will grade your performance.
PROCEDURE 21:4I
Giving a Complete Bed
Bath 3. Knock on the door and pause before
Equipment and Supplies 4. Screen the unit. Close all doors and
Bed linen (complete set); laundry hamper, windows. Eliminate drafts. Adjust the
bag, or cart; bath blanket; two to three wash- thermostat to a comfortable room tem-
cloths; face towel; one to two bath towels; perature, if possible.
soap and soap dish; basin; bath thermome-
5. Wash hands.
ter; clean gown or pajamas; supplies for hair
care; supplies for nail care; shaving supplies; NOTE: Gloves can be put on either at
oral hygiene supplies; lotion; disposable this point or during parts of the proce-
gloves; pen or pencil dure when contact with blood and body
fluids is likely, such as when administer-
Procedure ing oral hygiene and perineal care. If the
patient has a draining wound or the
1. Obtain authorization from your imme- patient’s skin is soiled with urine and
diate supervisor or check physician’s feces, gloves must be worn. Observe
orders to obtain authorization for the standard precautions.
procedure.
PROCEDURE 21:4I
6. Arrange all equipment conveniently. 14. With the washcloth, form a mitten
Put linen on the chair in the order of around your hand. Tuck in the loose
use. Position the laundry bag, hamper, edges (figure 21-43).
or cart conveniently.
NOTE: This prevents the loose edges of
NOTE: Proper preparation saves time the cloth from striking the patient as
and energy. you work. It also keeps water from drip-
ping on the patient and the bed.
ing height. Lower the siderail on the side 15. Wet the washcloth and squeeze out
where you are working. excess water. Wash the patient’s eyes
first. Start at the inner area and wash to
8. Replace the top linen with a bath blan-
the outside of the eye. Use a different
ket (figure 21-42). If the same linen is to
section of the cloth when you wash the
be reused, fanfold it to the bottom of the
second eye.
bed. If the linen is to be replaced, remove
it and place in the hamper. 16. Rinse the washcloth. Ask whether the
patient uses soap on the face and use
9. Provide oral hygiene as previously
soap if desired. Wash the face, neck, and
instructed.
ears. Rinse. Dry well.
10. Shave the male patient, if necessary.
17. Place a bath towel lengthwise under the
NOTE: Some patients prefer to be patient’s arm that is farthest from you.
shaved after the face is washed. Place the basin of water on the bed and
11. Fill the basin approximately two-thirds on the towel, at the lower end. Put the
full with warm water at a temperature of patient’s hand and nails into the water.
105–110°F (40.6–43.3°C). Check the tem- Wash, rinse, and dry the arm, from the
perature with a bath thermometer. axilla to the hand. Repeat for the other
arm.
12. Help the patient move to the side of the
bed nearest to you. Remove the patient’s NOTE: If the patient desires deodorant,
bedclothes as previously instructed. it can be applied after the axilla are clean
and dry.
13. Place a towel over the upper edge of the
bath blanket. 18. Provide nail and hand care as previously
instructed.
19. Elevate the siderail. Discard the bath
water and fill the basin with clean water
at 105–110°F.
20. Return to the bedside and lower the
siderail. Put a bath towel over the
patient’s chest. Fold the bath blanket
down to the patient’s waist.
21. Wash, rinse, and dry the chest and
breasts (figure 21-44). Pay particular
attention to the areas under a female
patient’s breasts. Dry these areas thor-
oughly.
FIGURE 21-42 Replace the top linen with a NOTE: A very small amount of lotion
bath blanket. may be placed under the breasts. Put
844 CHAPTER 21
PROCEDURE 21:4I
FIGURE 21-43 Fold the washcloth to form a bath mitten around your hand.
23. Fold the bath blanket up to expose the

patient’s leg that is farthest from you.
Place a towel lengthwise under the leg
and foot. Place the basin on the bed and
on top of the towel. Place the patient’s
foot in the basin by flexing the leg at the
knee. Wash and rinse the leg and foot,
remove the basin, and dry the leg and
foot. Repeat for the other leg.
NOTE: Support the patient’s leg and foot
with your hand and lower arm when
moving the foot in and out of the basin
(figure 21-45).
24. Provide nail care to the toes, as needed.
Never cut the toenails. File them straight
across. Apply lotion to the feet, if the
skin is dry. Never put lotion between the
FIGURE 21-44 Avoid exposing the patient toes because this promotes the growth
when washing the breasts. of fungus.
CAUTION: Observe for any color
changes or irritated areas that may sig-
the lotion in your hand first and then
nify problems.
apply it smoothly to the skin.
25. Elevate the siderail. Change the water in
22. Turn the bath towel lengthwise to cover
the basin.
the patient’s chest and abdomen. Fold
the bath blanket down to the pubic NOTE: Water should always be changed
area. Wash, rinse, and dry the abdomen. at this point in the bath. However, it can
Replace the bath blanket. Remove the be changed anytime it becomes too
towel. cool, dirty, or soapy.
PROCEDURE 21:4I
Pay particular attention to bony areas
and abnormal skin color. Report any
abnormality to your supervisor.
28. Give a backrub as previously instructed.
29. Help the patient turn onto his or her
back. Keep the patient draped with the
bath blanket.
30. If the patient is able to wash the perineal
area, place the basin with water, the
soap, the washcloth, the towel, and the
call signal within easy reach. Raise the
siderail and wait outside the unit while
the patient completes this procedure.
31. If the patient is not able to wash the per-
ineal area, put on gloves. Drape and
position the patient in the dorsal recum-
bent position. Put a towel or disposable
FIGURE 21-45 Support the leg when placing underpad under the patient’s buttocks
the patient’s foot in the basin. and upper legs.
a. For a female patient, always wash
26. Lower the siderail. from the front to the back, or rectal,
27. Turn the patient on his or her side or area. Separate the labia, or lips, and
into the prone position. Place the towel cleanse the area thoroughly with a
lengthwise on the bed and along the front-to-back motion (figure 21-47).
patient’s back. Wash, rinse, and dry the Use a clean area of the washcloth or
entire back (figure 21-46). rinse the cloth between each wipe.
CAUTION: Observe the back closely for b. For a male patient, cleanse the tip of
any changes that may signify problems. the penis using a circular motion and
FIGURE 21-47 To provide perineal care to a

FIGURE 21-46 Turn the patient on his or her female patient, separate the labia and cleanse
side to wash, rinse, and dry the back. the area with a front-to-back motion.
846 CHAPTER 21
PROCEDURE 21:4I
starting at the urinary meatus and tal area, turn a male patient on his
working outward. Cleanse the penis side.
from top to bottom (figure 21-48A). If
c. Rinse and dry all areas thoroughly on
a male patient is not circumcised,
both the male and female patient.
gently draw the foreskin back to wash
When the perineal area is clean, repo-
the area (figure 21-48B). After rinsing
sition the patient on his or her back
and drying the area, gently return the
and remove the towel or underpad
foreskin to its normal position. Wash
from under the buttocks. Remove
the scrotal area, taking care to clean
gloves and wash hands.
under the scrotum. To wash the rec-
NOTE: In some facilities, disposable
washcloths or large gauze pads are used
to clean the perineal area. These are dis-
carded in an infectious-waste bag and a
fresh washcloth or pad is used for each
area. Follow agency policy.
32. Place clean bedclothes on the patient as
previously instructed.
33. Provide hair care as previously taught.
34. Make the bed according to Procedure
21:3B, Making an Occupied Bed.
rect body alignment; elevate the side-
rails (if indicated); lower the bed to its
lowest level; and place the call signal,
FIGURE 21-48A Use a circular motion to water, tissues, and supplies within easy
cleanse the penis from the top to the base. reach of the patient.
36. Clean and replace all equipment. Wash
the emesis basin and bath basin thor-
oughly.
37. Put the bag or hamper of dirty linen in
the proper area or send it to the laundry
according to agency policy. Replace all
remaining equipment.
38. Remove gloves, if worn. Wash hands.
39. Report that a complete bed bath was
given and/or record all required infor-
complete bed bath given, occupied bed
FIGURE 21-48B If a male patient is not made, patient stated he was tired at end
circumcised, gently draw the foreskin back to of procedure; and your signature and
wash the area. After rinsing and drying the area, title. Report any observations that may
gently return the foreskin to its normal position. signify problems.
PROCEDURE 21:4I
Practice
Go to the workbook and use the evaluation sheet for 21:4I, Giving a Complete Bed Bath,
to practice this procedure. When you believe you have mastered this skill, sign the sheet
and give it to your instructor for further action.
Final Checkpoint Using the criteria listed on the evaluation sheet, your instructor will
grade your performance.
PROCEDURE 21:4J
NOTE: If the patient has visitors or is
Helping a Patient Take receiving another treatment, time and
a Tub Bath or Shower energy would be wasted in preparing
the tub or shower.
Equipment and Supplies 4. Wash hands. Put on gloves if necessary.
Washcloth, two to three towels, soap and soap CAUTION: Wear gloves and observe
dish, bathmat, rubber mat, bath thermome- standard precautions if contact with
ter, chair or stool (placed in bath area), bed- blood, body fluids, secretions, or excre-
clothes, robe, slippers, disposable gloves, pen tions is possible.
or pencil
5. Take the supplies to the bath or shower
area. Make sure the tub or shower is
Procedure clean. If it is dirty, put on gloves to clean
the tub or shower. Wipe it with a disin-
1. Check physician’s orders or obtain fectant (figure 21-49). When the tub or
authorization from your immediate shower is clean, remove gloves and wash
supervisor. A physician’s order is gener- your hands. If nonskid strips are not
ally required before a tub bath or shower present, put a rubber mat in the tub or
is allowed, unless the patient is consid- shower to prevent the patient from slip-
ered able to take care of this need (for ping. Place the bathmat on the floor. Fill
example, in the case of a totally ambula- the tub half full with water at 105°F, or
tory patient). 40.6°C.
2. Assemble equipment. NOTE: Many health care facilities have
3. Knock on the door and pause before shower or tub chairs that are used for
entering. Introduce yourself. Identify patients who cannot stand in a shower
the patient. Also, check to make sure the or climb into a tub (figure 21-50). The
time is appropriate for taking a shower shower chair must be cleaned and dis-
or bath. infected before and after every use.
848 CHAPTER 21
PROCEDURE 21:4J
7. If necessary, help the patient undress.
Help the patient into the tub or shower.
If a shower chair is used, transfer the
patient to the chair. Make sure the
wheels on the chair are locked before
transferring the patient.
CAUTION: Before the patient enters the
shower, adjust the temperature of the
shower water.
8. If necessary, remain with the patient
and assist with the bath or shower. If the
patient can manage without assistance,
explain how to use the emergency call
signal, leave the room, and check on the
patient at frequent intervals.
CAUTION: If the patient shows any signs
FIGURE 21-49 The tub should be cleaned of weakness or dizziness, use the call
and wiped with a disinfectant before and after button to get help. If the patient is in a
each use. tub, remove the plug and let the water
drain. If the patient is in a shower, turn
off the shower and seat the patient in
the chair. Keep the patient covered with
a towel or bath blanket to prevent chill-
ing.
CAUTION: Most long-term care facili-
ties require that you always stay with
the patient.
NOTE: In a home care situation, a small
bell (such as a dinner bell) can be left
with the patient.
9. When the patient is finished bathing,
help as needed. Dry all areas of the
patient’s body thoroughly. Put clean
bedclothes or clothing on the patient.
10. Assist the patient back to the bedside.
Administer a backrub. Help with hair or
nail care, if necessary.
FIGURE 21-50 A shower chair is often used
for patients who cannot stand in the shower or 11. Observe all checkpoints before leaving
climb into a tub. the patient: position the patient in cor-
rect body alignment, elevate the side-
6. Help the patient put on a robe and slip- rails (if indicated), lower the bed to its
pers. Take the patient to the bath or lowest level, place the call signal and
shower area. supplies within easy reach of the patient,
CAUTION: Use a wheelchair, if neces- and leave the area neat and clean.
sary.
PROCEDURE 21:4J
12. Return to the bath or shower area.
Replace all supplies and equipment
used. Put on gloves. Clean the tub or
shower thoroughly and wipe with a dis- Practice
infectant. Go to the workbook and use the
evaluation sheet for 21:4J, Helping a
NOTE: If a shower chair was used, clean Patient Take a Tub Bath or Shower,
and disinfect the chair. to practice this procedure. When you
13. Remove gloves. Wash hands. believe you have mastered this skill,
14. Report that a tub bath or shower was sign the sheet and give it to your
given and/or record all required infor- instructor for further action.
assisted with tub bath, patient tolerated
procedure well; and your signature and Final Checkpoint Using the criteria
title. Report any observations that may listed on the evaluation sheet, your
signify problems. instructor will grade your performance.
21:5 INFORMATION INTAKE

Measuring and Recording Intake Intake refers to all fluids taken in by the patient. The
and Output following routes and liquids must be considered:
A record of how much fluid is taken in ♦ Oral is intake by way of the mouth. Liquids
and eliminated by a patient often helps taken in orally include water, coffee, tea, milk,
a physician provide care to the patient. A large juices, and other beverages. In addition, soups,
part of the body is fluid, so there must be a bal- gelatin, ice cream, and other similar foods that
ance between the amount of fluid taken into the are liquid at room temperature also qualify for
body and the amount lost from the body. In a measurement. The nurse assistant often mea-
healthy individual, the fluid balance is usually sures and records or reports these amounts.
maintained by the body structures. However, if ♦ Tube feedings, or enteral feedings, are recorded
an individual has heart or kidney disease, or loses as oral intake or in a special column. They are
large amounts of fluids through vomiting, diar- used for patients who are unable to swallow,
rhea, excessive perspiration, or bleeding, the fluid for unconscious or comatose patients, or
balance may be abnormal. If excessive fluid is when certain digestive diseases occur. The
retained by the body, swelling, or edema, results. solution given contains all of the nutrients
If excessive fluid is lost from the body, dehydra- required by the body and is more nourishing
tion occurs. Either condition can lead to death if than an intravenous (IV) feeding. Enteral feed-
not treated. In such cases, physicians may order ings may be administered through a nasogas-
that a record be kept of all fluids taken in and dis- tric tube or a gastrostomy tube. A nasogastric
charged from the body. This record is usually (NG) tube is a tube inserted through the nose,
called an intake and output (I & O) record. down the esophagus, and into the stomach
An intake and output (I&O) record is a (figure 21-51A). A syringe can be used to instill
means of recording all fluids a person takes in food and/or medication into the NG tube (fig-
and eliminates during a certain period of time. ure 21-51B). A gastrostomy tube is surgically
Each agency has its own form, but most contain inserted through the abdominal skin and into
similar information. the stomach (figure 21-52). A feeding pump is
850 CHAPTER 21
FIGURE 21-51A A nasogastric tube is inserted

through the nose, down the esophagus, and into the
stomach.
FIGURE 21-52 A gastrostomy tube is surgically

inserted through the abdominal skin and into the
stomach.
FIGURE 21-51B A syringe can be used to instill

tube feedings and/or medication into the nasogas-
tric (NG) tube.
usually used to administer the solution (figure
21-53). A nurse or another legally authorized
team member will administer the enteral feed-
ing. The nurse assistant must keep the patient’s
head elevated 30–45 degrees during the feed-
ing and for approximately 30–60 minutes after
the feeding; make sure there are no kinks in
the tubing; use extreme caution when turning
or positioning the patient to avoid dislodging
the tubing; provide frequent oral hygiene; and
notify the nurse immediately if the alarm
sounds on the feeding pump, if the solution is
not flowing through the tubing, or if the solu-
tion container is low or empty.
♦ Intravenous (IV) refers to fluids given into a
vein. Blood units, plasma, and other intrave-
nous (IV) solutions are measured. This mea-
surement is the responsibility of the nurse or FIGURE 21-53 A feeding pump is usually used to
another legally authorized team member. administer tube or enteral feedings.
♦ Irrigation refers to fluid placed into tubes that

have been inserted in the body. Any fluid
removed is not considered to be intake and
is not recorded. For example, if a nasogastric
tube is irrigated with 80 milliliters (mL) of
solution and the same exact amount is imme-
diately drawn back out of the tube, this is not
recorded as intake. However, if 60 mL is with-
drawn, the intake is recorded as 20 mL (80
minus 60 is 20). This measurement is also the
responsibility of the nurse or another legally
authorized team member.
OUTPUT
FIGURE 21-54 Suction drainage from a hemo-
Output refers to all fluids eliminated by the vac, one type of wound drainage system, is
patient. The following routes and liquids must be recorded as irrigation output on an intake and
considered: output (I&O) record.
♦ Bowel movement (BM): Liquid bowel move-
ments are usually measured and recorded. A has calibrations for milliliters/cubic centimeters
solid or formed BM is usually noted in the and/or ounces on the side. It is similar to a mea-
remarks column or described under feces. The suring cup and is used to obtain accurate mea-
nurse assistant may measure and record or surements. The graduate should be held at eye
report this elimination. level or placed on a solid surface and viewed at
♦ Emesis: Anything that is vomited is measured eye level to accurately record amounts (figure
and recorded. Color, type, and other facts are 21-55). In addition, care must be taken when
usually noted in the remarks column. The adding or totaling the columns on the I&O record.
nurse assistant often measures and records or Most records contain totals for 8-hour and 24-
reports emesis. hour periods. (See figure 21-56 and study it care-
♦ Urine: All urine voided or drained via a cathe- fully.)
ter is measured and recorded. This measure-
ment may be the responsibility of the nurse
assistant. A urine output of less than 30 milli-
liters (mL) per hour must be reported.
♦ Irrigation: Any irrigation or suction drainage,
including drainage from nasogastric tubes,
hemo-vacs, chest tubes, and other drainage
tubes, is measured (figure 21-54). The type,
amount, color, and other facts are noted in
the remarks column. If an irrigating solution
is injected into a tube and more solution returns,
the excess amount is considered output. This
measurement is the responsibility of the nurse
or another legally authorized team member.
RECORDING INTAKE
AND OUTPUT (I&O)
I&O records must be accurate. All amounts must
be measured in graduates. A graduate is a con- FIGURE 21-55 Hold the graduate at eye level to
tainer that is made of plastic or stainless steel and obtain an accurate measurement.
852 CHAPTER 21
INTAKE AND OUTPUT RECORD

Family Name First Name Attending Physician Room No. Hosp. No.
Date
INTAKE OUTPUT OTHER REMARKS
TIME Oral I.V. Blood Urine Tube Emesis Feces
7 - 8 a.m.
8 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 - 12 noon
12 - 1 p.m.
1 - 2 p.m.
2 - 3 p.m.
8 HOUR
TOTAL
3 - 4 p.m.
4 - 5 p.m.
5 - 6 p.m.
6 - 7 p.m.
7 - 8 p.m.
8 - 9 p.m.
9 - 10 p.m.
10 - 11 p.m.
8 HOUR
TOTAL
11 - 12 p.m.
12 - 1 a.m.
1 - 2 a.m.
2 - 3 a.m.
3 - 4 a.m.
4 - 5 a.m.
5 - 6 a.m.
6 - 7 a.m.
8 HOUR
TOTAL
24 HOUR
TOTAL
TOTAL INTAKE TOTAL OUTPUT
FIGURE 21-56 A sample intake and output (I&O) record.

For I&O records, fluids are usually measured

in metric units. Approximate equivalents
for units of the metric system are as follows:
Metric Household
1 mL or 1 cc ⫽ 15 gtts (drops)
5 mL or cc ⫽ 1 tsp (teaspoon)
15 mL or cc ⫽ 1 tbsp (tablespoon)
30 mL or cc ⫽ 1 oz (ounce)
240 mL or cc ⫽ 1 cup (8 oz)
500 mL or cc ⫽ 1 pt (pint) 16 oz)
1,000 mL or cc ⫽ 1 qt (quart) (32 oz)
NOTE: Remember, 1 milliliter (mL) and 1 cubic
centimeter (cc) are the same amount. Therefore,
30 mL equals 30 cc.
Various agencies have different policies for FIGURE 21-57 A specimen collector to collect
recording I&O. In some agencies, the I&O record urine can be placed under the seat on the toilet.
is kept at the bedside. Team members note the
I&O of the patient and record the measurements
on the record. At times, the patient is even taught
to measure and write down the amounts. In other toilet tissue or expel a bowel movement into the
agencies, the I&O record is kept on the patient’s bedpan or urine collector. Male patients can be
chart. Measurements are noted on a slip of paper told to use a urinal. If patients are given correct
and reported. The nurse, unit secretary or clerk, instructions, they can cooperate, and accurate
or an authorized team member then records the records can be maintained.
information on the chart’s I&O form. Ascertain Standard precautions (discussed in Chapter
and follow the policy of your agency. 14:4) must be followed at all times when
Patients should be given careful instructions body fluids include urine, emesis, liquid bowel
when an I&O record is being kept. The movements, and drainage. Gloves must be worn
patient must inform health care providers when while the fluids are being measured and dis-
he or she drinks fluids not provided by the health carded. Hands must be washed frequently and
care team. Sometimes, the patient records how must always be washed immediately after gloves
many glasses of water or other liquids are con- are removed. If splashing or spraying of fluids is
sumed. Other times, the health care worker fills a possible, a mask, eye protection, and gown must
water pitcher and then checks the quantity be worn. The graduate or measuring device for
remaining before refilling the pitcher. The worker monitoring a patient’s output must be used for
then subtracts this quantity from the total amount that patient only. It should be discarded or steril-
originally in the pitcher and records the differ- ized according to agency policy when output is
ence as water intake. To avoid missing any no longer measured. Any areas contaminated by
amounts of oral intake, the health care worker body fluids when measurements are being
must also think about fluid intake every time a obtained must be wiped with a disinfectant. The
glass, cup, or water pitcher is removed from the health care provider must constantly take steps
unit. If visitors bring milkshakes or other liquids, to prevent the spread of infection.
the amounts of these must also be recorded.
Female patients should be asked to urinate in a STUDENT: Go to the workbook and complete
bedpan or to use a special urine collector that the assignment sheet for 21:5A, Measuring Intake
can be placed under the seat on the toilet (figure and Output. Then return and continue with the
21-57). Female patients must be told not to place procedure.
30216_21_Ch21_779-929.indd 853 1/16/08 9:21:46 PM

854 CHAPTER 21
PROCEDURE 21:5
by checking the times against the assign-
Recording Intake and ment sheet.
Output 7. Under intake, add each column for 8-
NOTE: Competency will be evaluated by way hour totals. For example, add all of the
of successful completion of several assign- amounts for oral intake between 7 A.M.
ment sheets rather than by way of the usual and 3 P.M. Do the same for each of
evaluation sheet. Follow the procedure steps the other columns for all three 8-hour
to complete the assignment sheets. periods.
CAUTION: Recheck your addition. The
Equipment and Supplies totals must be accurate.
Assignment sheets for this topic (assignment 8. Now add the three 8-hour totals together
sheets 1 to 5 for 21:5B), scrap paper, pen, cal- for each column (7 A.M. to 6 A.M) to get
culator (if permitted) the 24-hour total at the bottom of the
page. Do this for each column in intake
Procedure and each column in output.
NOTE: You should have a 24-hour total
1. Review the preceding Information sec-
for oral intake and another total for IV
tion, figure 21-56, and your completed
intake.
assignment sheet for 21:5A, Measuring
Intake and Output. 9. Recheck all work.
2. Assemble equipment. NOTE: If you make an error, draw one
red line through the error. Place your
3. Go to the workbook and carefully read
initials in red by the error line. Then use
assignment sheet 1 for 21:5B, Recording
a blue or black pen to write the correct
Intake and Output. It will be part of this
information on the record.
procedure. After reading it through once,
do the assignment based on the follow- 10. Give the paper to your instructor for
ing guidelines and instructions. grading. Replace all equipment used.
4. Use a pen to record all information. NOTE: The record must be neat and leg-
ible. All figures must be recorded in
a. Find the correct time line on the
metric units.
intake and output (I&O) record.
b. Find the correct column: for exam-
ple, oral intake or urine output.
c. Record the amounts stated on the Practice
assignment sheet in the correct block. Your instructor will grade
Number of milliliters (mL) for a cof- assignment sheet 1 for 21:5B,
fee cup and other containers are at Recording Intake and Output. When
the top of the I&O sheet. it is returned to you, note all
comments or corrections. Then
5. When the information on the assign-
complete assignment sheet 2 for
ment sheet has been recorded in the
21:5B, Recording Intake and
appropriate places on the I&O record,
Output. Give it to your instructor to
recheck all areas of the record.
grade. Again note comments or
6. Make sure you have entered observa- corrections. Repeat the process for
tions about color, type, and other facts assignment sheets 3, 4, and 5.
in the remarks columns. Make sure the
observations are on the right time lines Final Checkpoint Using the criteria
21:6 INFORMATION
Feeding a Patient
Good nutrition is an important part of a
patient’s treatment. It may be one of your
responsibilities to make mealtimes as pleasant as
possible for the patient. Mealtimes are often
regarded as a time for social interaction. Most
people prefer to eat with others. People who eat
alone often have poor appetites and poor nutri-
tion. In long-term care facilities, patients are
encouraged to eat in the dining room. This pro-
vides an opportunity for social interaction with
others. If a patient is confined to bed, it is impor-
tant to talk with the patient while serving the food
tray or feeding the patient.
Proper mealtime preparation is important. If
the patient is ready to eat when the tray arrives,
mealtime is likely to be more pleasant. Prepara-
tion before the tray is delivered includes:
♦ Offering the bedpan or urinal or assisting the
patient to the bathroom; clear the room of any
offensive odors by using a deodorizer or open-
ing a window
♦ Allowing the patient to wash his or her hands
and face, if desired
♦ Providing oral hygiene, if desired; many indi-
viduals want to brush their teeth before meals, FIGURE 21-58A Check the food tray carefully
especially before breakfast against the patient’s name, room number, and type
♦ Positioning the patient comfortably and in a of diet ordered.
sitting position, if possible
♦ Clearing the overbed table and positioning it opening beverage cartons, and buttering bread
for the tray (figure 21-58B). If a patient is blind or visually
♦ Removing objects such as an emesis basin or impaired, tell the patient what food is on the plate
bedpan from the patient’s view; place such by comparing the plate to a clock. For example,
objects in the bedside stand, if they will not be say, “Swiss steak is at 12 o’clock, peas and carrots
needed are at 4 o’clock, and mashed potatoes are at
9 o’clock.” Make sure all food and utensils are
If a meal will be delayed because of radio- conveniently placed.
graphs (X-rays) or other treatments, be sure to Before feeding any patient, test the tempera-
explain this to the patient. ture of all hot foods. A small amount can be placed
Check the tray carefully against the patient’s on your wrist to check temperature. Never blow
name and room number and the type of diet on hot food to cool it.
ordered (figure 21-58A). If anything seems out of Points to observe when feeding a patient
place (for example, a salt shaker provided with a include:
salt-free diet, or sugar with a diabetic diet), check
with your immediate supervisor or the dietitian. ♦ Alternate the foods by giving sips of liquids
Never add any food to the tray without checking between solid foods.
the diet order first. ♦ Use straws for liquids unless the patient has
Allow patients to feed themselves whenever dysphagia (difficulty in swallowing). Straws
possible. If necessary, assist by cutting meat, can force liquids down the throat faster and
856 CHAPTER 21
FIGURE 21-59 It is important to observe how

much a patient eats so that a record of nutritional
intake can be maintained.
Observe how much the patient eats so that a
record of nutritional intake can be kept (fig-
ure 21-59). If the patient does not like certain
foods on the tray, ask your immediate supervisor
or the dietitian whether a substitute can be pro-
vided. Record intake if an intake and output (I&O)
record is being kept for the patient.
FIGURE 21-58B Assist the patient by cutting CAUTION: Always be alert to signs of chok-
meat, opening beverage cartons, and positioning
ing while feeding a patient. Take every effort
the food conveniently.
to prevent choking by feeding small quanti-
ties, allowing the patient time to chew and
swallow, and providing liquids to keep the
cause choking. A food thickener can be added mouth moist and make chewing and swal-
to liquids to solidify them slightly and make lowing easier. If a patient had a stroke, one
them easier to swallow. A physician or dieti- side of the mouth may be affected. As you
tian must approve the use of this product. feed the patient, direct food to the unaf-
fected side. Watch the patient’s throat to
♦ Offer only small bites of food at one time. Fill check swallowing. Watch for food that may
the spoon or fork one-third to one-half full be lodged in the affected side of the mouth.
♦ Hold the spoon or fork at right angles to the If a patient chokes on food, be prepared
patient’s mouth so you are feeding the patient to provide abdominal thrusts as described
from the tip of the utensil. in Procedure 16:2E, Performing CPR-
♦ Encourage the patient to eat as much as pos- Obstructed Airway on Conscious Adult or
sible. Child.
♦ Provide a relaxed, unhurried atmosphere. STUDENT: Go to the workbook and complete
♦ Give the patient sufficient time to chew the the assignment sheet for 21:6, Feeding a Patient.
food. Then return and continue with the procedure.
PROCEDURE 21:6
7. If the patient can feed himself or herself,
Feeding a Patient arrange all food and silverware conve-
niently. Cut meat, butter bread, and
Equipment and Supplies open beverage cartons.
Food tray with diet card, flex straws, towel, 8. To feed a patient, proceed as follows:
pen or pencil a. Follow the patient’s preference for
the order of foods eaten.
Procedure b. Test hot liquids on your wrist before
1. Obtain proper authorization and assem- giving them to the patient (figure
ble equipment. 21-60A). Wipe away any food placed
on your wrist.
entering. Introduce yourself. Identify NOTE: Never blow on the food to cool it.
the patient. Explain that it is almost time Never taste the patient’s food. This can
to eat. Close the door and screen the transmit infection.
unit to provide privacy. c. Use drinking straws for liquids unless
3. Wash hands. Put on gloves if contact the patient has dysphagia. Use a sep-
with oral fluids is possible. arate straw for each liquid offered.
Give the patient a drink of water to
4. Prepare the patient for mealtime. Pro- wet the palate and make swallowing
vide oral hygiene, if desired. Help the easier.
patient use the bedpan, as needed. Posi-
tion the patient in a sitting position, if d. Hold utensils at a right angle (90
permitted. Allow the patient to wash degree) to the patient’s mouth (figure
his or her hands and face. Position the 21-60B). Feed the patient from the
overbed table and remove unnecessary tip of the utensil.
articles. e. Place a small amount of food on the
NOTE: Make sure the patient is not utensil. Fill the spoon or fork about
scheduled for radiographs or any other one-third to one-half full.
treatment requiring the tray to be with-
held.
5. Check the tray. Match the name on the
diet card with the patient’s identifica-
tion band if one is worn. Check the type
of diet ordered to make sure the food on
the tray is correct. Do not add anything
to the tray without first checking with
your supervisor.
NOTE: If any foods seem to be incorrect
for the diet ordered, check immediately
with your supervisor.
6. Place the tray on the overbed table.
Place a towel or napkin under the
patient’s chin.
FIGURE 21-60A Test hot liquids before
feeding them to a patient.
858 CHAPTER 21
PROCEDURE 21:6
10. When the meal is complete, allow the
patient to wash his or her hands. Pro-
vide oral hygiene. Position the patient
comfortably and in correct body align-
ment.
the patient: elevate the siderails, if indi-
cated; lower the bed to its lowest level;
place the call signal and supplies within
easy reach of the patient; and leave the
12. Note how much food was eaten. Record
amounts on the I&O record, if one is
being kept.
NOTE: In many health care facilities, the
FIGURE 21-60B Hold utensils at a right supervisor must be notified if the patient
angle to the mouth to feed the patient from the refuses food and/or liquids or eats less
tip of the utensil. than 25 percent of the food.
f. Tell the patient what he or she is 13. Clean and replace all equipment. Place
eating. the tray in the correct area.
g. If the patient had a stroke, place food 14. Wash hands.

in the unaffected side of the mouth. 15. Report that the patient has been fed
Watch the throat to make sure the and/or record all required information
patient is swallowing. on the patient’s chart or the agency
h. Allow time for the patient to chew. form; for example, date; time; fed break-
Do not hurry the patient. fast, ate everything except one-half slice
toast; and your signature and title.
i. Alternate foods, but don’t mix foods
together. Provide liquids at intervals
to keep the mouth moist and make
chewing and swallowing easier.
j. Allow the patient to hold bread and
to help to the extent that he or she is Practice
able. Go to the workbook and use the
evaluation sheet for 21:6, Feeding a
k. Use a towel or napkin to wipe the Patient, to practice this procedure.
patient’s mouth, as necessary. When you believe you have
CAUTION: Be alert at all times to signs mastered this skill, sign the sheet
of dysphagia and/or choking. and give it to your instructor for
further action.
9. Encourage the patient to eat as much as
possible.
NOTE: If the patient does not like a par-
ticular food, check with your immediate Final Checkpoint Using the criteria
supervisor or the dietitian about substi- listed on the evaluation sheet, your
tute foods. instructor will grade your performance.
Accurate observations of the frequency,

21:7 INFORMATION amount, and appearance of urine and stool are
important. Abnormalities in any of these factors
Assisting with a Bedpan/Urinal may indicate disease or complications. Any
Regular elimination of body wastes contrib- abnormality must be reported immediately, and
utes to good health. Patients confined to a specimen must be saved for examination.
bed must rely on the health care worker’s help in Prior to emptying a bedpan or urinal, it is the
meeting this important physical need. health care worker’s responsibility to check
Elimination of body wastes is essential. Death whether specimens are needed. In addition,
will occur if wastes are not eliminated. The fol- amounts must be measured and recorded if an
lowing terms are used in reference to elimina- intake and output (I&O) record is being kept for
tion: the patient. Check with your immediate supervi-
♦ Urinate, micturate, or void: These terms sor or note physician’s orders for this informa-
refer to emptying of the bladder, which stores tion.
the liquid waste, or urine, produced by the Standard precautions must be observed
kidney. A urinal is used by male patients when when handling urine or feces. Hands must
they need to urinate, micturate, or void; a bed- be washed frequently, and gloves must be worn.
pan is used by female patients. Two main Eye protection must be worn if splashing or
types of bedpans are the fracture, or orthope- spraying is possible while emptying the bedpan.
dic, bedpan and the standard bedpan (figure Some health care facilities require a one-glove
21-61). technique to protect the environment while
assisting with bedpans or urinals. Two gloves are
♦ Defecate: This refers to having a bowel move-
ment, or BM; the discharge of the waste
through the rectum. The material is called
feces or stool.
Many patients are sensitive about using bed-
pans or urinals. It is important that the health
care worker provide privacy by closing the door,
privacy curtain, and window curtain. Make the
patient as comfortable as possible during this
procedure. It is also important to provide the
bedpan or urinal immediately when the patient
requests it. In addition, a bedpan or urinal should
be offered frequently to any patient confined to
bed.
FIGURE 21-61 Two types of bedpans: the FIGURE 21-62 Some agencies have special
fracture, or orthopedic, bedpan (at left) and the spray units in the bathrooms to rinse and clean
standard bedpan (at right). bedpans and urinals.
860 CHAPTER 21
worn to remove the bedpan or urinal. The bed- only one patient. After the patient is discharged,
pan or urinal is covered and placed on top of an it must be sterilized according to agency policy
underpad or bed protector that has been placed before being used for another patient. Some
on a chair. The bedpan or urinal should never be bedpans are disposable and are discarded in an
placed on the overbed table or bedside stand. infectious-waste container when the patient is
One glove is removed and held in the gloved discharged. Any areas contaminated by urine or
hand. The ungloved hand is used to elevate the feces must be wiped with a disinfectant. In addi-
siderails, open doors, and turn on faucets. A tion, patients should have the opportunity to
paper towel can also be used with a gloved hand wash their hands and receive perineal care after
to prevent contact with items in the environment. using bedpans or urinals. Taking proper precau-
It is important to protect environmental surfaces tions can help prevent the spread of infection.
from contamination with substances on gloved
hands.
Some agencies have special spray units in the STUDENT: Go to the workbook and complete
bathrooms to rinse and clean bedpans and uri- the assignment sheet for 21:7, Assisting with a
nals (figure 21-62). After rinsing, the bedpan or Bedpan/Urinal. Then return and continue with
urinal must be disinfected. It must be used for the procedures.
PROCEDURE 21:7A
CAUTION: Use correct body mechanics
Assisting with during this procedure. Bend from the
a Bedpan hips, not the waist. Maintain a broad
base of support.
Equipment and Supplies 5. If the bedpan is metal, warm it by run-
ning hot water into it and then empty-
Bedpan with cover, bed protector or under-
ing it. If no water is available, rub the
pad, toilet tissue, basin, soap, washcloth,
bedpan briskly with a cloth.
towel, disposable gloves, plastic waste bag,
pen or pencil 6. Lower the siderails on the side where
you are working.
Procedure 7. Fold the top bedcovers back at a right
angle. Raise the patient’s gown.
ble equipment. NOTE: Avoid exposing the patient. If the
patient is wearing pajama pants, help
2. Knock on the door and pause before lower the pants.
the patient. Explain the procedure. NOTE: The patient can also be covered
with a bath blanket. The top sheets are
3. Wash hands. Put on gloves. then fanfolded to the foot of the bed.
CAUTION: Observe standard precau- 8. Ask the patient to flex the knees and rest
tions when handling urine or feces. his or her weight on the heels, if able.
4. Close the door and screen the unit. Put a Discuss a signal such as, “On the count
bed protector or underpad on the chair of three, raise up.”
and then place the bedpan on top. Place 9. At the signal, assist the patient to raise
the tissue within easy reach of the his or her hips by putting one of your
patient. Raise the bed to a comfortable hands under the small of the patient’s
working height. Lower the head of the back (figure 21-63A).
bed, if tolerated by the patient.
PROCEDURE 21:7A
FIGURE 21-63A Ask the patient to raise his

or her hips so that the bedpan can be put in
position.
FIGURE 21-63B The patient can also turn
onto his or her side so that the bedpan can be
positioned. The patient then rolls back onto the
CAUTION: If the patient is too heavy, bedpan.
get help.
10. With your other hand, slide the bedpan 14. Place the call signal and tissue within
under the patient’s hips. The narrow end easy reach of the patient.
should face the foot of bed. Adjust to the NOTE: If a urine specimen is needed or
correct placement. the patient is on Intake and Output,
NOTE: The patient’s buttocks should instruct the patient not to put toilet tis-
rest on the rounded portion of the pan. sue in the pan. Provide a small plastic
bag for discarding the soiled tissue.
11. The patient who is too weak to get on
the pan may be rolled away from the 15. Raise the siderail before leaving the
health care worker and onto his or her patient.
side. The bedpan can then be placed 16. Wash hands thoroughly.
against the patient’s buttocks (figure
17. Answer the patient’s call signal immedi-
21-63B). The patient is then rolled back
ately.
onto the bedpan. The bedpan must be
held in place during this procedure. 18. Wash hands.
NOTE: Lower bedpans, called fracture 19. Fill the bath basin with water at 105–
(or orthopedic) bedpans, can also be 110°F. Place the basin on the overbed
used by patients who are unable to help table or bedside stand. Position soap, a
(refer again to figure 21-61). wash cloth, and towel by the basin.
12. Remove gloves and place them in the 20. Put on gloves.
plastic waste bag.
21. Lower the siderail. Ask the patient to flex
13. Replace the top bedcovers. Position the the knees and put his or her weight on
patient in a comfortable position. Raise the heels. Place one hand under the
the head of the bed, as needed. small of the patient’s back. Assist in rais-
862 CHAPTER 21
PROCEDURE 21:7A
ing the patient’s buttocks off the pan. being kept for the patient, measure and
With your other hand, remove the bed- record the amount.
pan carefully.
NOTE: Check to see whether a specimen
22. Cover the bedpan and place it on the is needed before emptying the bedpan.
underpad on top of the chair.
CAUTION: Save a sample of the con-
NOTE: If a bedpan cover is not available, tents if there are any abnormalities.
cloth, paper bags, or tissue paper can be
32. Empty the bedpan. Use a paper towel to
used to cover the bedpan.
cover your gloved hand while turning
23. If the patient is unable to assist in get- on the faucet or flushing the toilet. Put
ting off the bedpan, it may be necessary on eye protection if spraying or splash-
to get help. Roll the patient off the bed- ing is possible. Rinse the bedpan with
pan and onto his or her side while hold- cold water and a disinfectant. Rinse and
ing the bedpan firmly in place with one dry.
hand. Cover the bedpan and place it on
NOTE: Follow your agency’s policy for
the underpad on top of the chair.
cleaning bedpans.
24. Clean the genital area, as necessary.
33. Return the covered pan to the patient’s
Wipe from front to back. Drop the soiled
unit. Use a paper towel on the gloved
tissue into the bedpan, unless a speci-
hand or remove one glove. Replace all
men is needed or output is being mea-
equipment used.
sured. In these situations, temporarily
place the tissue in a plastic bag until you 34. Remove gloves. Wash hands thoroughly.
can discard it in the toilet or trash can in 35. Report and/or record all required infor-
the utility room. mation on the patient’s chart or the
25. Wash the patient’s perineal area, if nec- agency form; for example, date; time;
essary, or assist the patient as needed. used bedpan, voided 250 mL of straw
yellow urine; and your signature and
26. Remove gloves and place them in the
title. Always report unusual observa-
plastic bag.
tions immediately.
27. Replace the bedcovers. Elevate the
siderails, if necessary.
29. Empty the bath basin and refill it with
warm water. Allow the patient to wash Practice
his or her hands. Go to the workbook and use the
evaluation sheet for 21:7A, Assisting
30. Observe all checkpoints before leaving with a Bedpan, to practice this
the patient: position the patient in cor- procedure. When you believe you
rect body alignment; elevate the side-
rails (if indicated); lower the bed to its
lowest level; and place the call signal,
for further action.
water, and tissues within easy reach of
the patient.
31. Put on gloves. Take the bedpan to the
bathroom. Note the contents. Check Final Checkpoint Using the criteria
amount, color, type. If an I&O record is listed on the evaluation sheet, your
PROCEDURE 21:7B
vate the siderail with the ungloved hand
Assisting with before leaving.
a Urinal 7. Remove gloves and wash hands.
Equipment and Supplies 8. Answer the patient’s call signal immedi-

ately.
Urinal with cover, bed protector or underpad,
9. Wash hands.
basin, soap, washcloth, towel, toilet tissue,
disposable gloves, plastic waste bag, pen or 10. Fill the bath basin with water at 105–
pencil 110°F. Place the basin on the overbed
table or bedside stand. Position soap, a
Procedure wash cloth, and towel by the basin.
11. Put on gloves.
ble equipment. Make sure the urinal has 12. Ask the patient to hand you the urinal. If
a lid or cover of some type (figure 21-64). the patient needs assistance, reach
under the covers and take hold of the
2. Knock on the door and pause before urinal handle. Close the lid or cover the
entering. Introduce yourself. Identify top of the urinal and place it on top of
the patient. Explain the procedure. the underpad on the chair.
3. Wash hands. Put on gloves. NOTE: Avoid exposing the patient.
CAUTION: Observe standard precau- 13. Wash the patient’s perineal area, if nec-
tions when handling urine or feces. essary, or assist the patient, as needed.
4. Close the door and screen the unit. Ele- 14. Remove gloves and place them in the
vate the bed to a comfortable working plastic waste bag.
height. Lower the siderail on the side
where you are working. 15. Replace the bedcovers. Elevate the sid-
erails, if necessary.
5. If the patient is weak or helpless, lift the
top bedcovers and help the patient 16. Wash hands thoroughly.
grasp the handle and position the 17. Empty the basin and refill it with warm
urinal. water. Allow the patient to wash his
6. Make sure the call signal and toilet tis- hands or assist as needed.
sue are within easy reach of the patient. 18. Observe all checkpoints before leaving
Leave the patient alone, if possible, to the patient: position the patient in cor-
ensure privacy. Remove one glove. Ele- rect body alignment, elevate the side-
rails, if indicated; lower the bed to its
lowest level; and place the call signal
and supplies within easy reach of the
patient.
19. Put on gloves.
20. Take the urinal to the bathroom. Observe
the contents. Measure and record the
amount if an I&O record is being kept
for the patient.
FIGURE 21-64 A urinal should have a lid or NOTE: Check to see whether a specimen
cover.
is needed before emptying the urinal.
864 CHAPTER 21
PROCEDURE 21:7B
CAUTION: Save a specimen if there are used urinal, voided 250 mL of straw yel-
any abnormalities. Report unusual low urine; and your signature and title.
observations immediately to your Always report unusual observations
supervisor. immediately.
21. Empty the urinal. Use a paper towel to
cover your gloved hand while turning
on the faucet or flushing the toilet. Put
on eye protection if spraying or splash-
ing is possible. Rinse the urinal with
cold water and a disinfectant. Rinse and Practice
dry. Go to the workbook and use the
NOTE: Follow agency policy for clean- evaluation sheet for 21–7B, Assisting
ing the urinal. with a Urinal, to practice this
22. Return the urinal to the patient’s unit.
Use a paper towel on the gloved hand or
remove one glove. Place it in the bedside
for further action.
stand or in the urinal holder on the
bed.
24. Report and/or record all required infor- Final Checkpoint Using the criteria
mation on the patient’s chart or the listed on the evaluation sheet, your
agency form; for example, date; time; instructor will grade your performance.
catheter) is usually used to drain the bladder over

21:8 INFORMATION an extended period of time. It has a small balloon
on the end that is inserted in the bladder (figure
Providing Catheter and Urinary 21-65B). Once the catheter is inserted, the bal-
loon is inflated with sterile water to keep the
Drainage Unit Care catheter in place. The catheter must be kept ster-
Some patients are unable to urinate, or void. ile at all times. Insertion of a catheter is a sterile
In these cases, a catheter may be inserted technique performed by a nurse, physician, or
into the bladder to drain the urine. The catheter other authorized person. If a male patient requires
is usually connected to a drainage unit to collect urinary drainage, external condom catheters may
the urine. be used (figure 21-65C). The condom catheters
A catheter is a hollow tube, usually made of eliminate the need for an internal catheter and
soft rubber or plastic. There are different kinds of decrease the chance of urinary infection. The
catheters. A French, or straight, catheter is condom catheter is placed on the penis and
inserted into the bladder to drain urine but is not attached to the urinary-drainage tubing and col-
left in the bladder (figure 21-65A). It is usually lection bag. The condom must be removed at
used to collect a sterile urine specimen. A Foley least every 24 hours, and the skin must be checked
catheter (also called an indwelling, or retention, for any signs of irritation.
FIGURE 21-65A A straight catheter is inserted

into the bladder to drain urine but is not left in the
bladder.
FIGURE 21-65B A Foley catheter has a small

balloon on the end that is inserted in the bladder.
The balloon is inflated with sterile water to hold the
catheter in place.
FIGURE 21-66A The urinary-drainage bag is

connected to the catheter and attached to the bed
frame below the level of the bladder to collect the
drained urine. (Courtesy of Medline Industries, Inc.
1-800-MEDLINE)
FIGURE 21-65C Condom catheters are used to

provide an external urinary-drainage system for
male patients.
A urinary-drainage unit or bag is attached

to the catheter to collect drained urine (figure Image not available due to copyright restrictions
21-66A). This is usually a closed unit to keep
microorganisms from entering the catheter and,
therefore, prevent infection. The unit consists of
plastic or rubber tubing attached to the catheter
and extending to a bag in which the urine is col-
lected. Patients who are ambulatory may use a
leg bag to collect the urine drained through the
catheter (figure 21-66B). The leg bag is smaller
than a urinary-drainage bag and must be emp-
tied more frequently. However, it does allow the
patient more freedom of movement. Most leg
bags are held in place with Velcro straps. The bag bags are discarded in an infectious-waste bag
must be positioned so there is a straight drop after one use. To prevent infection, careful asep-
down from the catheter. When the patient returns tic technique must be used while connecting and
to bed, the leg bag is removed and the catheter is disconnecting the catheter from either a urinary-
connected to a urinary-drainage bag. Most leg drainage bag or a leg bag.
866 CHAPTER 21
Careful observation of the catheter and drain- urine specimen is required (because the urine in
age unit is required. The following should be the bag is not fresh and is contaminated), the
checked frequently: drainage unit must be disconnected. In either
instance, careful sterile technique must be fol-
♦ The connection between the catheter and lowed to prevent infection. Both the catheter and
drainage unit is secure.
top connection of the drainage unit must be kept
♦ The tubing is free from kinks or bends that sterile. Special clamps, plugs, and other equip-
stop the urine flow. ment are available for disconnecting the catheter
♦ The drainage bag is always below the level of (figure 21-67A). Follow agency policy for discon-
the bladder. If it is raised above the level of the necting the catheter. Usually, the catheter is
bladder, a backflow of urine into the bladder clamped to prevent leakage of urine. The health
can occur. This can, in turn, lead to infection. care worker wears gloves to disconnect the cath-
eter from the tubing, taking care to avoid touch-
♦ The urine is flowing freely into the drainage ing the ends of the catheter or tubing to any
bag. The system usually relies on gravity for
surface. A plug is inserted into the catheter, and a
drainage. Therefore, the drainage bag should
cap is placed on the end of the drainage tubing
be kept low enough to make use of the force of
(figure 21-67B). The drainage tubing is attached
gravity.
to the bed frame so it cannot touch the floor or
♦ The catheter is taped, strapped, or tied to the become contaminated before it is reconnected.
patient’s leg. This prevents pull on the cathe- Most drainage units have special urine-
ter, which might dislodge it or cause irrita- collection areas on the tubing. The catheter does
tion.
♦ The drainage unit is emptied frequently. Stag-
nant urine encourages the growth of microor-
ganisms. The units are usually emptied every
8 hours, but they may be emptied more fre-
quently, if required.
♦ The drainage bag is not lying on the floor. It
should be attached to the bed frame.
♦ No loops of the drainage tube are hanging
below the drainage bag. Such loops interfere
with the gravitational flow of urine into the
bag. FIGURE 21-67A A sterile catheter plug and
protective cap.
♦ The drainage tubing leading to the drainage
bag is always above the level of urine in the
unit. This prevents infection and microorgan-
isms in the urine from traveling back up the
tubing and into the patient’s bladder.
♦ If a patient complains of burning, pain, irrita-
tion, or tenderness in the urethral area, the
complaints should be reported immediately
to the supervisor.
When a catheter and urinary-drainage unit is
in place, it is preferable to never disconnect the
drainage unit. However, it may sometimes be
necessary to disconnect the catheter from the
unit. For example, if a patient uses a leg bag dur-
ing ambulation, the catheter is disconnected
from the urinary drainage unit and attached to FIGURE 21-67B A catheter disconnected from
the leg bag. If a urine-collection area is not pres- the drainage tube and protected with the catheter
ent on the drainage unit, and a sterile or fresh plug. Note the protective cap on the drainage tube.
not have to be disconnected when a specimen is free of secretions to help prevent bladder and
obtained from this type of unit. Follow the spe- kidney infections. Catheter care is provided for
cific instructions provided with the unit or follow this purpose, and it should be administered at
agency policy to maintain sterility during this least once every 8 hours, and more frequently if
procedure. A clamp is usually placed on the tub- ordered. This care is usually provided during the
ing below the collection unit to allow urine to col- bath and as part of perineal care. Disposable
lect in the tubing and/or bladder. The collection catheter-care kits containing applicators and
unit is wiped with a disinfectant, and a sterile antiseptic solution are used in many agencies.
needle and syringe is inserted into the unit to Other agencies use soap and water. Some kits
obtain the urine specimen (figures 21-68A and also contain disposable bed protectors or under-
B). The urine is then placed in a specimen con- pads and gloves. Follow the instructions provided
tainer. Gloves must be worn during this proce- with the kit or the procedure recommended by
dure, and the contaminated needle and syringe your agency. Procedure 21:8A describes one
must be placed in a sharps container immedi- method of catheter care.
ately after use. Careful observations of the urine drained
When a Foley, or indwelling, catheter is in should be made. The amount, color, type,
place, the urinary meatus must be kept clean and presence of other substances, and other observa-
tions should be noted. Unusual observations
should be reported immediately.
Correct procedure must be followed when
emptying the drainage unit to prevent contami-
nation and infection. Procedure 21:8B describes
one way of emptying a drainage unit.
If a patient has had an indwelling catheter in
place over a period of time, a bladder-training
program may be instituted before the catheter is
removed. The purpose of a bladder-training pro-
gram is to develop voluntary control of urination
and prevent incontinence, or the inability to con-
trol urination. At first, the catheter is clamped for
1–2 hours at a time to allow urine to accumulate
in the bladder. The clamp is then released, and
urine is allowed to drain into the urinary-
FIGURE 21-68A The urine-collection area is first drainage unit bag. The time is gradually increased
wiped with a disinfectant. until the catheter is clamped for 3–4 hours at a
time. After the catheter is removed, the patient is
encouraged to void every 3–4 hours or whenever
necessary to regain bladder control. Bladder-
training programs can also be used for inconti-
nent patients who do not have indwelling
catheters in place. This type of program encour-
ages the patient to attempt to void at regularly
scheduled intervals. A record is kept of times of
incontinence to establish when the patient
should be encouraged to void. Staff members
then assist the patient to the bathroom or offer
the bedpan or urinal before the expected time of
incontinence. The support, understanding, and
cooperation of all staff members is important
when a bladder-training program is used for a
patient.
FIGURE 21-68B A sterile needle and syringe are Standard precautions (discussed in Chapter
then used to obtain the urine specimen. 14:4) must be observed at all times when
868 CHAPTER 21
handling urine. Gloves must be worn when pro- Taking proper precautions helps prevent the
viding catheter care, obtaining urine specimens spread of infection.
from a urine-collection unit, and emptying a uri-
nary-drainage unit. Hands must be washed fre-
quently, and immediately after removing gloves. STUDENT: Go to the workbook and complete
If splashing or spraying of body fluids is possible, the assignment sheet for 21:8, Providing Catheter
eye protection must be worn. Any areas contami- and Urinary-Drainage Unit Care. Then return
nated by urine must be wiped with a disinfectant. and continue with the procedures.
PROCEDURE 21:8A
6. Cover the patient with a bath blanket.
Providing Without exposing the patient, fanfold
Catheter Care the top bed linen to the foot of the bed.
7. Place the disposable underpad or bed
Equipment and Supplies protector under the patient’s buttocks
and upper legs.
Catheter-care kit (or sterile applicators, bowl,
and antiseptic solution or soap and water), 8. Position the patient in the dorsal recum-
bath blanket, disposable underpad or bed bent position, if possible, with the legs
protector, catheter strap or tape (if needed), separated and knees bent. Drape the
disposable gloves, plastic waste bag, pen or patient so that only the perineal area is
pencil exposed.
NOTE: Catheter care is usually administered 9. Open the catheter-care kit and place it
after the perineal area has been washed and on the overbed table. Position the plas-
cleaned during the bath. If administered at a tic waste bag conveniently.
different time, equipment must be obtained
10. Put on gloves.
to wash and clean the perineal area before
providing catheter care. NOTE: Sterile gloves are required by
some agencies. Follow agency policy.
Procedure 11. Obtain a sterile applicator (usually a
cotton ball or gauze pad) moistened
1. Obtain proper authorization and assem- with antiseptic solution or soap and
ble equipment. water.
2. Knock on the door and pause before NOTE: Some kits contain premoistened
entering. Introduce yourself. Identify sterile applicators. Other kits contain
the patient. Explain the procedure. containers of antiseptic solution that
3. Close the door and screen the unit for must be poured into small bowls pro-
privacy. vided with the kits. The sterile applica-
tor is then placed in the antiseptic.
4. Wash hands.
12. For a female patient:
standard precautions when providing a. Use the thumb and forefinger of one
catheter care. hand to gently separate the labia, or
lips, and expose the urinary meatus
(opening).
where you are working. b. Wipe from front to back with the ster-
ile applicator.
PROCEDURE 21:8A
c. Place the used applicator in the plas-
tic waste bag.
d. Using a clean sterile applicator each
time, continue to wipe from front to
back until the area is clean.
13. For a male patient:
a. Gently grasp the penis and draw the
foreskin back.
b. Use the sterile applicator to wipe
from the meatus down the shaft. FIGURE 21-69A Check the catheter to be
c. Place the used applicator in the plas- sure it is strapped to the leg.
tic waste bag.
d. Using a clean sterile applicator each
time, continue to wipe from the
meatus down the shaft until the area
is clean.
e. After the area is clean, gently return
the foreskin to its normal position.
14. Without pulling on the catheter, use a
sterile applicator to clean the catheter
from the meatus down approximately
4 inches. Place the used applicator in the
plastic waste bag. Repeat as necessary,
using a fresh applicator for each stroke. FIGURE 21-69B The catheter may also be
15. Observe the area carefully for any signs taped to the leg. If possible, use hypoallergenic
of irritation, abnormal discharge, or tape.
crusting. 21. Observe all checkpoints before leaving
16. Remove the bed protector or underpad the patient: elevate the siderails (if indi-
and place it in the plastic waste bag. cated); place the call signal, water, and
supplies within easy reach of the patient;
17. Remove gloves and discard in the plastic
lower the bed to its lowest level; and
waste bag. Wash hands.
leave the area neat and clean.
18. Check the catheter to be sure it is
22. Perform a final check of the catheter
strapped or taped to the leg (figures
and drainage unit to ensure the follow-
21-69A and B). Reposition the strap or
ing:
replace the tape, if necessary.
a. The tubing is free of kinks and
CAUTION: Make sure there is no strain
bends.
or pull on the catheter.
b. The tubing is positioned to allow for
19. Position the patient comfortably and in
proper flow of urine. Do not allow
correct body alignment.
excess tubing to hang below the
20. Replace the top bed linen and remove drainage bag. Coil the excess tubing
the bath blanket. on the bed so the tubing hangs
straight down into the drainage bag.
870 CHAPTER 21
PROCEDURE 21:8A
c. The drainage bag is attached to the
bed frame.
d. The drainage bag is below the level of
the bladder.
Practice
e. The drainage tubing is above the level evaluation sheet for 21:8A,
of the urine in the bag. Providing Catheter Care, to practice
f. Urine is flowing into the drainage
bag.
23. Place all disposable supplies in the plas- instructor for further action.
tic waste bag. Seal properly and dispose
of in the correct area. Clean and prop-
erly replace any other equipment used.
25. Report and/or record all required infor-
catheter care given, urine flowing into
drainage bag; and your signature and Final Checkpoint Using the criteria
title. Report any unusual observations listed on the evaluation sheet, your
immediately. instructor will grade your performance.
PROCEDURE 21:8B
Emptying a Urinary- tions when measuring urine.
Drainage Unit 4. Place paper towels on the floor. Place
the measuring graduated cylinder on
Equipment and Supplies top of the towels.
Paper towels, graduated cylinder or pitcher, 5. Remove the drainage outlet from the
antiseptic or disinfectant swab, disposable drainage bag. Place the end of the outlet
gloves, plastic waste bag, paper, pen or pencil in the measuring pitcher.
CAUTION: Do not allow the end of the
Procedure outlet to touch the graduated cylinder.
1. Obtain proper authorization and assem- 6. Release the clamp to allow the urine
ble equipment. to drain. Empty all the urine (figure
21-70A).
entering. Introduce yourself. Identify NOTE: If necessary, tilt the bag to remove
the patient. Explain the procedure. all the urine.
3. Wash hands. Put on gloves. Wear eye 7. Clamp the drainage tube. Wipe the
protection if spraying or splashing of drainage outlet with an antiseptic or
body fluids is possible. disinfectant swab (figure 21-70B). Dis-
PROCEDURE 21:8B
card the antiseptic wipe in the plastic e. The drainage bag is below the level of
waste bag. Replace the tube in the unit the bladder.
(figure 21-70C).
f. The drainage tubing is above the level
8. Observe all checkpoints before leaving of the urine in the bag.
the patient: position the patient com-
g. Urine is flowing into the bag.
fortably and in correct body alignment,
elevate the siderails (if indicated), lower 10. Pick up the graduate and paper towel.
the bed to its lowest level, place the call Discard the paper towel in the plastic
signal and supplies within easy reach of waste bag.
the patient, and leave the area neat and 11. Take the graduate to the patient’s bath-
clean. room. Place the graduate on a paper
9. Perform a final check of the catheter towel on a counter and read the mea-
and unit to ensure the following: surement at eye level. Record the
amount and color of urine in the gradu-
a. The catheter is strapped or taped to
ate. Record any unusual observations
the patient’s leg.
and report such observations immedi-
b. The tubing is free of kinks and ately.
bends.
NOTE: Save a specimen if needed, or if
c. The tubing does not loop down below anything unusual is noted about the
the drainage bag. Do not allow excess urine.
tubing to hang below the drainage
12. Empty the graduate into the toilet. Rinse
bag. Coil the excess tubing on the bed
it with cold water. Wash with soap and
so the tubing hangs straight down
warm water. Clean with a disinfectant.
into the drainage bag.
Rinse and dry. Return to its proper
d. The drainage bag is attached to the place.
bed frame.
FIGURE 21-70A Drain the FIGURE 21-70B Wipe the FIGURE 21-70C Replace the
urine from the urinary-drainage drainage outlet with a disinfec- drainage tube in the drainage
unit. tant. unit.
872 CHAPTER 21
PROCEDURE 21:8B
NOTE: The graduate is usually kept in
the patient unit. It should be used for
one patient only. Most agencies use dis-
posable graduates. If the graduate is not Practice
disposable, it should be sterilized Go to the workbook and use the
according to agency policy before being evaluation sheet for 21:8B,
used for another patient. Emptying a Urinary-Drainage Unit
14. Report and/or record all required infor- sign the sheet and give it to your
mation on the patient’s chart or the instructor for further action.
emptied urinary-drainage unit, 580 mL
of light yellow urine; and your signature Final Checkpoint Using the criteria
and title. Report any unusual observa- listed on the evaluation sheet, your
tions immediately. instructor will grade your performance.
intestine involved (figure 21-71). Stool expelled

21:9 INFORMATION through an ascending colostomy tends to be liq-
uid, while stool expelled through a transverse or
Providing Ostomy Care descending colostomy is more solid and formed.
An ostomy is a surgical procedure in which an Stool expelled through a sigmoid colostomy is
opening, called a stoma, is created in the abdom- similar to normal stool, because the digestive
inal wall. This allows wastes such as urine or stool products have moved through most of the intes-
(feces) to be expelled through the opening. In tine, and water and other substances have been
most cases, an ostomy is performed because of reabsorbed.
tumors and/or cancer in the urinary bladder or Most patients with ostomies wear a bag or
intestine. An ostomy may also be done as a treat- pouch over the stoma to collect the drainage (fig-
ment for birth defects, ulcerative colitis, bowel ure 21-72). The pouch is held in place with a belt
obstruction, or injury. At times, an ostomy is per- or an adhesive seal. Problems that can occur
manent. At other times, an ostomy is temporary include leakage, odor, and irritation of the skin
and is repaired when the injury heals or the con- surrounding the stoma. The pouch must be emp-
dition necessitating the ostomy improves. tied frequently. Many pouches have areas that
There are different types of ostomies. A ure- can be opened to allow urine or stool to drain.
terostomy is an opening into one of the The drainage end of the bag is placed in a bedpan
two ureters that drain urine from the kidney to (figure 21-73). If the patient is up, the patient can
the bladder. The ureter is brought to the surface sit on the toilet and position the drainage end of
of the abdomen, and urine drains from the stoma, the bag over the toilet. The clamp at the drainage
or opening. An ileostomy is an opening into the end of the bag is opened to allow the stool or
ileum, a section of the small intestine. A loop of urine to drain. The drainage end is then cleaned
the ileum is brought to the surface of the abdo- to prevent odors and the clamp is resealed. Some
men. Because the entire large intestine is pouches are disposable and are removed and
bypassed, the stools expelled are frequent and replaced. Used bags should be discarded in an
liquid, and contain digestive enzymes that irri- infectious-waste bag.
tate the skin. A colostomy is an opening into the Good stoma and skin care is essential because
large intestine, or colon. There are different kinds of irritation caused by urine or stool drainage.
of colostomies, depending on the area of large Skin barriers such as wafers, pastes, powders, and
A. Ascending colostomy B. Transverse colostomy C. Descending colostomy D. Sigmoid colostomy

FIGURE 21-71 The type of colostomy depends on which part of the intestine is removed. Areas of intestine
that remain after each type of colostomy are shown in blue.
A
B
E
FIGURE 21-73 To empty the ostomy pouch,
place the drainage end in a bedpan.
A. Adhesive ring seals around Patients with ostomies may experience psy-
stoma to prevent leakage chological reactions. They may feel loss of per-
B. Opening placed over stoma sonal worth and dignity because they are unable
C. Collection bag
to eliminate body wastes in a routine manner.
D. Drainage end of bag
E. Secures drainage end of
Even though clothing conceals the ostomy and
bag to prevent leakage pouch, the patient feels different. Some individu-
FIGURE 21-72 Most patients with ostomies wear als have difficulty in maintaining normal sexual
a bag or pouch over the stoma, or opening, to relationships. Others may feel anger, anxiety,
collect the drainage. depression, fear, or hopelessness. If the ostomy is
done because of a malignant tumor (cancer), fear
liquid films frequently are applied to the skin and anxiety can be more severe. It is essential to
around the stoma to prevent irritation from the allow the patient to express feelings and verbalize
removal of the pouch. fears. Understanding and support from all health
When an ostomy is first performed, care is care providers is important during the period of
provided by a registered nurse. For “older” initial adjustment. Eventually, patients realize
ostomies, other trained and qualified health care that thousands of people with ostomies live nor-
workers may provide routine stoma care. It is mal lives. Through ostomy support groups, made
essential to check the policy of your facility and up of people with ostomies, and help from health
to know your legal responsibilities before provid- care providers, most individuals learn to cope
ing ostomy care. Eventually, most patients are and live with their ostomies.
taught to care for their own ostomies, if they are Careful observation is essential when provid-
capable. ing care to the patient with an ostomy. The stoma
874 CHAPTER 21
is mucous membrane with no nerve endings. It is ing, ulcerations or cuts, or the formation of crys-
bright to dark red and looks wet because of the tals on the stoma also indicate problems. The
exposed mucosa (figure 21-74). Rubbing or pres- discharge in the ostomy bag or pouch should also
sure can cause the stoma to bleed. Any abnor- be observed. It is important to note the amount,
malities in appearance should be reported color, and type (liquid, semi-formed, formed) of
immediately. A blue to black color indicates inter- discharge. Any unusual observations should be
ference with the blood supply. A pale or pink color reported to your immediate supervisor and/or
can indicate a low hemoglobin level. A dry or dull recorded on the patient’s chart or the agency
appearance signifies dehydration. Profuse bleed- form.
14:4) must be observed at all times when
handling urine or stool. Gloves must be worn
when emptying the pouch or providing stoma
care. Hands must be washed frequently, and
immediately after removing gloves. Eye protec-
tion must be worn if splashing or spraying of
body fluids is possible. The pouch must be dis-
carded in an infectious-waste or plastic waste
bag. If a bedpan is used, it must be cleaned and
disinfected. Any areas contaminated with urine
or stool must be wiped with a disinfectant. Taking
proper precautions can help prevent the spread
of infection.

FIGURE 21-74 A stoma should be bright to dark the assignment sheet for 21:9, Providing Ostomy
red and look wet because of the exposed mucous Care. Then return and continue with the proce-
membrane. dure.
PROCEDURE 21:9
CAUTION: Know your legal responsi-
Providing Ostomy bilities before providing ostomy care.
Care 2. Assemble equipment.
Equipment and Supplies 3. Knock on the door and pause before

Washcloth, towel, soap, basin, bed protector the patient. Explain the procedure.
or underpad, bath blanket, ostomy pouch or
4. Close the door and screen the unit for
bag, ostomy belt, adhesive (if needed), skin
privacy.
barrier or wafer (as ordered), toilet tissue,
bedpan, disposable gloves, infectious-waste 5. Wash hands.
bag, pen or pencil 6. Fill the basin with water at a tempera-
ture of 105–110°F (40.6–43.3°C). Place
Procedure the bedpan and plastic waste bag within
easy reach.
1. Check physician’s orders or obtain
authorization from your immediate 7. Lock the wheels of the bed. Elevate the
supervisor. bed to a comfortable working height.
PROCEDURE 21:9
Lower the siderail on the side where you 14. Wash the ostomy area gently with soap
are working. and water. Use a circular motion, work-
ing from the stoma outward.
Without exposing the patient, fanfold 15. Rinse the entire area well to remove any
the top bed linen to the foot of the bed. soapy residue. Dry the area gently with a
towel.
9. Place a bed protector or underpad under
the patient’s hips on the side of the NOTE: Make sure soap is removed. It
stoma. has a drying effect and may irritate the
skin.
10. Put on disposable gloves.
16. Use a measuring chart to check the size
CAUTION: Observe standard precau- of the stoma and determine the correct
tions at all times when handling urine size barrier or wafer (figure 21-75A). If
or feces. the wafer is not self-adhesive, apply
11. Open the belt and carefully remove the adhesive stoma paste to the skin around
ostomy bag. Be gentle when peeling the the stoma. Some pastes must dry a few
bag away from the stoma. Note the minutes; follow manufacturer’s instruc-
amount, color, and type of drainage in tions. Peel the paper backing from the
the bag. Place the bag in the bedpan or wafer. Position the wafer, adhesive side
infectious-waste bag. Follow agency down, over the adhesive paste (figure
policy. 21-75B).
NOTE: Most ostomy bags are dispos- NOTE: The wafer serves as a barrier
able, but some are reusable. To reuse a between the ostomy pouch or bag and
bag, drain the fecal material (or urine the skin. It is not changed every time the
from a ureterostomy) by placing the pouch is changed.
clamp end of the bag over a bedpan. NOTE: Some types of ostomy pouches
Then release the clamp and allow the and bags do not use wafers. Instead,
fecal material to empty into the bedpan. barriers in the forms of pastes, liquids,
Wash the inside of the bag with soap or powders are applied to the skin to
and water and allow it to dry before protect it. Follow manufacturer’s
reapplying the bag. Most people use a instructions.
second bag while the first bag is drying.
12. Use toilet tissue to gently wipe around
the stoma to remove feces or drain-
age. Put the tissue in the bedpan or
NOTE: If the patient has a ureterostomy,
wipe urine from the stoma area to pre-
vent the urine from contacting the skin.
13. Carefully examine the stoma and sur-
rounding skin. Check for irritated areas,
bleeding, edema (or swelling), or dis-
charge. Make sure you report any
unusual observations to your imme-
diate supervisor at the end of the pro- FIGURE 21-75A Check the size of the stoma
cedure. to determine the correct size for the barrier or
wafer.
876 CHAPTER 21
PROCEDURE 21:9
cated); lower the bed to its lowest level;
and place the call signal, water, tissues,
and other supplies within easy reach of
the patient.
24. Wash hands thoroughly and put on
gloves.
25. Take the bedpan and waste bag to the
bathroom. Follow agency policy for dis-
posal of the ostomy pouch or bag. In
some agencies, the bag is emptied into
the bedpan. The contents of the bedpan
are then flushed down the toilet. The
ostomy pouch or bag is then placed in
FIGURE 21-75B Position the wafer, adhesive an infectious-waste bag. In other agen-
side down, around the stoma. cies, the full bag is put in an infectious-
17. Position the belt around the patient. If waste bag. Rinse the bedpan with cool
necessary, apply a clean belt. water and a disinfectant. Then rinse and
dry it. Discard any other contaminated
18. Gently press a clean ostomy bag in place
supplies in an infectious-waste bag.
over the wafer (figure 21-75C). Seal the
bag tightly to the wafer to prevent leak- 26. Return the covered bedpan to the
age. patient’s unit. Replace all equipment
used. Leave the area neat and clean.
19. If the pouch has a drainage area, make
sure the clip or clamp sealing the drain- 27. Remove gloves. Wash hands thoroughly.
age site is secure. 28. Report and/or record all required infor-
20. Remove the underpad or bed protector. mation, on the patient’s chart or the
If any linen on the bed is soiled, change agency form, for example, date; time;
the linen. provided ostomy care, pouch three-
fourths full of semi-formed light brown
stool; and your signature and title.
Always report unusual observations
22. Replace the top bed linen and remove immediately.
the bath blanket. Make sure the patient
is comfortable and positioned in correct
body alignment.
the patient: elevate the siderails (if indi- Practice
evaluation sheet for 21:9, Providing
Ostomy Care, to practice this
for further action.

FIGURE 21-75C Gently press the ostomy listed on the evaluation sheet, your
bag in place over the wafer. instructor will grade your performance.
21:10 INFORMATION
Collecting Stool/Urine
Specimens
As a health care worker, you may be responsible
for collecting stool and urine specimens. Labora-
tory tests are performed on the specimens to aid
in diagnosis of disease. For the tests to be accu-
rate, the specimens must be collected correctly.
Types of specimens include routine urine speci-
men; clean-catch, or midstream-voided, speci-
men; catheterization for sterile urine specimen;
24-hour urine specimen; routine stool specimen;
and stool for occult blood.
ROUTINE URINE
SPECIMEN FIGURE 21-76 A specimen collector to collect
urine or stool specimens can be positioned on the
♦ A routine urine specimen is one of the most toilet under the seat.
common specimens. It is used for a variety of
laboratory tests such as urinalysis (described
in Information section 19:10). The specimen is
usually collected from the first urine voided in ♦ If a specimen container is not available, any
the morning because this urine is more con- clean container can be used. Wash the con-
centrated and may reveal more abnormalities. tainer thoroughly with soap and water, then
In addition, a first-voided specimen usually rinse and dry it. Patients should be cautioned
has an acidic pH, which helps preserve any against using containers that previously held
cells present. However, for tests such as glu- medications, however, because using such
cose and acetone, the specimen is usually col- containers can alter the results of the test.
lected just before mealtime or bedtime and is
a fresh specimen. Check with the physician,
team leader, laboratory technologist, or other CLEAN-CATCH, OR
person in charge to find out when the speci-
men should be collected. MIDSTREAM-VOIDED,
♦ The specimen can be collected in a bedpan, SPECIMEN
urinal, or special specimen collector posi-
tioned on a toilet under the seat (figure 21-76). ♦ A Midstream (clean-catch) specimen is a
The collected urine is then poured into the urine specimen that is free from contamina-
specimen container. It may also be collected tion. Because microorganisms are present on
by instructing the patient to void directly into the genital area and on the specimen contain-
the specimen container. ers, special precautions are used to obtain a
♦ Usually, 120 milliliters (mL) of urine is suffi- specimen.
cient for this test. If the patient is unable to ♦ A sterile urine-specimen container, free from
void this amount, obtain what is available and all microorganisms, is used to collect a mid-
send this amount to the laboratory. stream specimen.
♦ The specimen should be sent to the laboratory ♦ The genital area is cleansed thoroughly. This
immediately. If this is not possible, refriger- can be done by the health care worker, or the
ate the specimen until it can be sent to the patient can be given careful instructions on
laboratory. how to do this procedure. Clean cotton
878 CHAPTER 21
sponges or gauze squares and a mild antisep- ♦ Specimen collection catheters are also avail-
tic solution are used. able for obtaining a sterile urine specimen
♦ On a female patient, the genital area includes (figure 21-77). These units contain a very small
the perineum and the vulva. The vulva consists catheter attached to a collection test tube. The
of two prominent folds, called the labia majora, catheter is inserted into the bladder and urine
and the structures within them: the labia drains directly into the tube. When the tube is
minora, the urinary opening, the clitoris, and full, the catheter is withdrawn. The catheter is
the vagina. Moist cotton or gauze wipes are then separated from the tube and discarded in
used to clean the external lips of the vulva. They a sharps container. The tube is sealed by press-
are wiped from front to back. After each wipe, ing on the spout.
the cotton or gauze square is discarded. The ♦ Only a trained person should insert the cath-
internal lips are then cleaned. Finally, the center eter. However, if a catheter is already in
area is cleaned from front to back. The center place, you may collect a urine specimen for
area contains the urinary opening (meatus). the sterile container (refer to figures 21-68A
♦ On a male patient, a circular motion is used. and B). It is important that you work under
Starting at the urinary meatus (opening) at the supervision and use sterile technique to pre-
tip of the penis, the end is cleaned thoroughly vent contamination of the catheter when
in a circular downward motion. Each cotton obtaining the specimen.
or gauze square is discarded after each wipe.
NOTE: On uncircumcised male patients, the
foreskin should be pushed back before clean- 24-HOUR URINE
ing. After the end of the penis is clean, gently SPECIMENS
push the foreskin back into its normal posi-
tion. ♦ Special tests require a 24-hour urine speci-
♦ After the area has been cleaned, the patient is men. This means that all of the urine pro-
told to urinate, or void. A few drops of urine duced by the patient during a 24-hour period
are allowed to flow into the bedpan or toilet must be saved. This urine is used to check kid-
bowl. The sterile container is then used to ney function and components such as pro-
catch the urine that follows. The last few drops tein, creatinine, urobilinogen, hormones, and
of urine should be discarded. In this way, the calcium.
first and last part of the specimen are dis- ♦ The urine is preserved by way of chemicals
carded, and only the middle, or midstream, and/or cold storage. The laboratory sends the
urine is collected.
♦ The sterile lid of the container should be
placed on this specimen immediately to pre-
vent contamination. The specimen should be
sent to the laboratory immediately or be refrig-
erated.
CATHETERIZATION
FOR STERILE URINE
SPECIMEN
♦ It is sometimes necessary to obtain a sterile
urine specimen from a patient. In order to do
this, the patient is catheterized. A narrow, hol- FIGURE 21-77 This Speci-Cath kit is designed to
low, sterile tube is inserted directly into the obtain a sterile urine specimen from a male patient.
bladder. Urine from the tube is then placed in (Courtesy of Medline Industries, Inc., Mundelein, IL.
a sterile urine-specimen container. [800-MEDLINE.])
correct container and instructions for pre-

serving the specimen (figure 21-78). ROUTINE STOOL
♦ To start, the patient voids to empty the blad- SPECIMEN
der. This urine is discarded because it was
produced before the start of the 24-hour ♦ A stool (feces) specimen is examined by the
period. The time of voiding is noted as the laboratory, usually to check for ova and para-
start of the 24-hour period. All urine voided in sites (eggs and worms). Stool can also be
the next 24 hours is saved in the special con- examined for the presence of fats, microor-
tainer. At the end of the 24-hour period, the ganisms, and other abnormal substances. A
patient voids again for the final collection of new experimental stool test, currently being
urine. researched, checks for a gene or a DNA muta-
♦ If any specimen is accidentally discarded dur- tion that is usually faulty in the earliest stages
ing the 24-hour period, the test must be dis- of colon cancer. If this test is approved, it will
continued and restarted. In addition, toilet help physicians detect colon cancer at its ear-
tissue cannot be discarded in any specimen. liest stages when it can be treated much more
The tissue must be discarded in a plastic waste effectively.
bag or toilet. ♦ The stool is placed in a special stool-specimen
container.
♦ The container should be kept at body
temperature, and the specimen sent to the
laboratory immediately. For the most accu-
rate results, it should be examined within
30 minutes.
STOOL FOR OCCULT

BLOOD
♦ Sometimes occult blood (blood from areas
of the intestinal tract) can be found in the
stool. Testing for occult blood requires only a
small amount of stool.
♦ A special card is usually used for this test. The
small specimen of stool is placed on a desig-
nated section(s) of the card (figure 21-79).
♦ The card is sent to the laboratory or checked
immediately by an authorized individual in
some health care facilities. A few drops of a
special developing solution, such as Hemoc-
cult, is added to the area. A color change indi-
cates a positive result.
♦ A positive test means that blood is present in
the stool.
♦ The test for occult blood does not require that
the stool be kept warm or that it be examined
immediately. However, it should be sent to the
FIGURE 21-78 Different types of specimen laboratory as soon as possible so that the
collectors for collecting 24-hour urine specimens. specimen is not misplaced.
880 CHAPTER 21
address, the date and time, and the physician’s

name. It is best to label the specimen container
instead of the lid because errors could occur if
the lid is misplaced. All required information
must also be printed on the correct lab requisi-
tion form. A lab requisition must be sent with the
labeled specimen.
14:4) must be observed when obtaining and
handling urine or stool specimens. Gloves must
be worn. Hands must be washed frequently and
are always washed immediately after removing
gloves. Eye protection must be worn if splashing
or spraying of body fluids is possible. Any areas
contaminated by urine or stool must be wiped
with a disinfectant. To avoid contamination from
spills, all urine or stool specimens are placed in
special biohazard bags before being transported
FIGURE 21-79 A small specimen of stool is placed to the laboratory for testing. Taking proper
on the Hemoccult card to test for occult blood.
precautions can help prevent the spread of
infection.
SUMMARY STUDENT: Go to the workbook and complete
All specimens must be labeled correctly, the assignment sheet for 21:10, Collecting Stool/
including the kind of specimen (urine or Urine Specimens. Then return and continue with
stool), the test ordered, the patient’s name and the procedures.
PROCEDURE 21:10A
Collecting a Routine
Urine Specimen entering. Introduce yourself. Identify
Equipment and Supplies the patient.
Bedpan with cover/urinal or specimen col- 4. Wash hands. Put on gloves.
lector, urine-specimen container and label,
toilet tissue, graduated or measuring pitcher,
tions when obtaining and handling
disposable gloves, plastic waste bag, biohaz-
urine specimens.
ard bag, pen or pencil
5. If the patient is ambulatory, assist the
Procedure patient to the bathroom.
a. Place a specimen collector on the
1. Check physician’s orders or obtain toilet and then reposition the toilet
authorization from your immediate seat.
supervisor to be sure you are collecting
the right type of specimen. b. Instruct the patient to discard the
toilet tissue into the toilet and not
NOTE: In most cases, the first-voided into the specimen collector. A plastic
specimen of the day is collected.
PROCEDURE 21:10A
waste bag can also be provided for 13. Wash the outside of the container to
the discarded tissue. remove any spilled urine. Remove
gloves. Wash hands.
c. Provide privacy while the patient
voids. Make sure the call signal and CAUTION: Do not allow water to enter
toilet tissue are within reach. the container. Water will dilute the urine
specimen and affect the accuracy of the
d. After the specimen has been col-
test results.
lected, assist the patient back to a
chair or bed. 14. Place the cover on the container.
6. If the patient is not ambulatory, offer 15. Label the container. Include the date,
the bedpan or urinal as previously time, patient’s name and room or hospi-
instructed in Procedure 21:7A or 21:7B. tal number or address, specimen type,
test required, and physician’s name.
a. Advise the patient not to put toilet
Print required information on the cor-
tissue in the bedpan or urinal. Pro-
rect lab requisition or obtain the requi-
vide a plastic waste bag for disposal
sition from your immediate supervisor.
of soiled toilet tissue.
A lab requisition must be sent with the
b. After the patient has voided, remove labeled specimen.
the bedpan or urinal. Place it on top
of an underpad or bed protector that
has been placed on the chair. CAUTION: Remember to wear gloves
and observe standard precautions when
7. Remove gloves and wash hands thor-
cleaning any equipment or area con-
oughly.
taminated by urine.
8. When the specimen has been obtained,
17. Put the specimen in a protective bio-
allow the patient to wash his or her
hazard bag for transport (figure 21-80).
hands.
Take or send the specimen to the labo-
9. Observe all checkpoints before leaving ratory immediately. Report the arrival of
the patient: position the patient com- the specimen to laboratory personnel. If
fortably and in correct body alignment, this is not possible, refrigerate the speci-
elevate the siderails (if indicated), place men until it can be sent to the labora-
the call signal and supplies within easy tory.
reach of the patient, lower the bed to its
lowest level, and leave the area neat and
clean.
10. Put on clean gloves.
11. Take the bedpan or urinal to the patient’s
bathroom or remove the specimen col-
lector from the toilet. Pour the urine
into a measuring pitcher.
NOTE: Record the amount if an intake
and output (I&O) record is being kept
for the patient.
12. Pour approximately 120 milliliters into FIGURE 21-80 All specimens must be placed
the urine-specimen container. in protective biohazard bags before being
transported to the laboratory.
882 CHAPTER 21
PROCEDURE 21:10A
mation on patient’s chart or the agency
form, for example, date, time, routine
Practice
urine specimen collected and sent to evaluation sheet for 21:10A,
lab, and your signature and title. Collecting a Routine Urine
Specimen, to practice this
PROCEDURE 21:10B
Lower the siderail on the side where you
Collecting a are working. If the patient is able, the
Midstream Urine specimen can be collected in the bath-
Specimen room. If the patient is not ambulatory,
provide a bedpan or urinal as instructed
in Procedure 21:7A or 21:7B.
6. Place the gauze or cotton squares in the
Sterile urine-specimen bottle and label, gauze basin. Pour the required amount of anti-
or cotton squares, antiseptic solution, small septic solution into the basin. In many
basin, plastic waste bag, biohazard bag, dis- agencies, a special kit is available for
posable gloves, underpad or bed protector (if collecting midstream specimens. Fol-
needed), pen or pencil low the instructions that come with the
kit, if one is used.
Procedure NOTE: In some agencies premoistened
1. Check physician’s orders or obtain antiseptic pads are used. Under these
authorization from your immediate circumstances, the basin and antiseptic
supervisor to be sure you are collecting solution would not be necessary.
the correct type of specimen. 7. Put on disposable gloves.
2. Assemble equipment. CAUTION: Wear gloves and observe
3. Knock on the door and pause before standard precautions when obtaining
entering. Introduce yourself. Identify urine specimens.
the patient. Explain the procedure to 8. Wash the genital area correctly or
the patient. instruct the patient on how to do so.
4. Wash hands. a. For a female patient, use antiseptic
5. Close the door and screen the unit to and gauze squares. Clean the outer
provide privacy for the patient. Elevate folds from front to back. Use a clean
the bed to a comfortable working height. gauze for each wipe. Discard each
PROCEDURE 21:10B
gauze in the plastic waste bag after
one use. Clean the inner folds (lips)
from front to back, using a clean
gauze for each wipe. Discard each
gauze after use. Finally, clean the
innermost (middle) area from front
to back. Discard soiled gauze.
b. For a male patient, use a circular
motion to clean from the urinary
meatus outward and downward. Dis-
card each gauze after one wipe in the
plastic waste bag. Repeat at least two
times or until the area is clean.
NOTE: On uncircumcised male
patients, the foreskin should be pushed
back before cleaning. After cleaning, FIGURE 21-81 Place the sterile cap on the
gently push the foreskin back to its container immediately after collecting the urine
normal position. specimen.
9. Instruct the patient to void. Allow the
first part of the stream to escape. Catch
the middle of the stream in the sterile 12. Observe all checkpoints before leaving
specimen container. Allow the last part the patient: position the patient in cor-
of the stream to escape. rect body alignment, elevate the side-
NOTE: If the amount must be measured rails (if indicated), lower the bed to its
because an intake and output (I&O) lowest level, place the call signal and
record is being kept for the patient, supplies within easy reach of the patient,
catch the first and last urine in a bedpan and leave the area neat and clean.
or urinal or in a specimen collector if NOTE: Use a paper towel with a gloved
the patient is on the toilet. hand or a one-glove method to avoid
10. Place the sterile cap on the container contaminating the environment.
immediately to prevent contamination 13. Wash the outside of the container.
of the specimen (figure 21-81). Remove gloves and wash hands.
CAUTION: Do not touch the inside of 14. Label the container as a “Midstream” or
the specimen container or the inside of “Clean-Catch” specimen. Print the
the lid because this will contaminate the name of the ordered test, the patient’s
specimen. name and room number or address, the
NOTE: Some midstream-specimen con- date and time, and physician’s name on
tainers have a funnel that aids in the the label. Print required information on
collection of the specimen. This is the correct lab requisition or obtain the
removed and discarded in the plastic requisition from your immediate super-
waste bag before the sterile cap is placed visor. A lab requisition must be sent with
on the container. the labeled specimen.
11. Allow the patient to wash his or her 15. Clean and replace all equipment.
hands. CAUTION: Remember to wear gloves
and observe standard precautions when
884 CHAPTER 21
PROCEDURE 21:10B
cleaning any equipment or area con-
taminated by urine.
hazard bag for transport. Take or send
Practice
the specimen to the laboratory immedi- evaluation sheet for 21:10B,
ately. Report the arrival of the specimen Collecting a Midstream Urine
to laboratory personnel. If this is not Specimen, to practice this
possible, refrigerate the specimen until
it can be sent to the laboratory.
NOTE: For the most accurate results, the sheet and give it to your instructor
specimen should be examined as soon for further action.
as possible.
midstream urine specimen collected Final Checkpoint Using the criteria
and sent to laboratory, and your signa- listed on the evaluation sheet, your
ture and title. instructor will grade your performance.
PROCEDURE 21:10C
ing the 24 hours. The laboratory will
Collecting a 24-Hour supply information on the correct
Urine Specimen method for preserving the specimen.
Equipment and Supplies 4. Label the container with the patient’s
24-hour specimen container and label, sign name and room number or address, the
for patient’s bed, graduate (if urine is to be test ordered, the specimen type, the
measured), disposable gloves, plastic waste date, and the physician’s name.
bag, biohazard bag, pen or pencil
Procedure the patient. Explain the procedure. Tell
the patient not to discard toilet tissue in
1. Check physician’s orders or obtain the urine specimen. Provide a plastic
authorization from your immediate waste bag for disposal of toilet tissue.
supervisor to be sure you are collecting
the correct specimen. NOTE: Make sure the patient under-
stands the entire procedure. Stress the
2. Check on the type of container and pre- importance of saving all urine.
servative required.
6. Wash hands. Put on disposable gloves.
NOTE: Some containers for certain tests
contain chemical preservatives. Others CAUTION: Remember to wear gloves
must be kept on ice or refrigerated dur- and observe standard precautions when
PROCEDURE 21:10C
obtaining urine and placing it in a 24- 11. At the end of the 24-hour period, ask the
hour specimen container. patient to void. Add this urine to the
7. Allow the patient to void. Assist with the specimen container. It is the final void-
bedpan or urinal, if necessary. Measure ing of the procedure.
the amount, if an intake and output 12. Remove the sign from the patient’s bed.
(I&O) record is being kept for the patient.
13. Check the specimen label to make sure
Discard this specimen. Note the time of
it is accurate and contains all required
voiding as the start of the 24-hour
information. Print required information
period.
on the correct lab requisition or obtain
NOTE: Urine voided at this time has the requisition from your immediate
been produced before the 24-hour time supervisor. A lab requisition must be
period. The patient must begin the 24- sent with the labeled specimen.
hour period with an empty bladder.
NOTE: For female patients allowed to hazard bag for transport. Take or send
use the bathroom, a specimen collector the specimen to the laboratory immedi-
can be placed under the seat in the toi- ately. Notify laboratory personnel of the
let (refer to figure 21-76). The patient specimen’s arrival.
must be told not to discard toilet tissue
or defecate in the specimen collector. NOTE: For the most accurate results,
urine should go to the laboratory as
soon as possible.
9. Place a sign on the patient’s bed and/or
in the bathroom to alert others that a 15. Replace all equipment used.
24-hour specimen is being collected. 16. Remove gloves. Wash hands thoroughly.
The sign usually states, “Save all urine—
24-hour specimen.”
10. During the 24-hour period, use the agency form, for example, date, time,
specimen container to collect all urine 24-hour urine specimen completed and
voided (figure 21-82). sent to laboratory, and your signature
NOTE: If any urine is discarded, the pro- and title.
cedure must be stopped and started
again.
Practice
Collecting a 24-Hour Urine
Specimen, to practice this
for further action.
FIGURE 21-82 All urine voided during the Final Checkpoint Using the criteria
24-hour period must be placed in the specimen listed on the evaluation sheet, your
container. instructor will grade your performance.
886 CHAPTER 21
PROCEDURE 21:10D
9. Place the lid on the container. Make sure
Collecting a Stool it is tightly in place.
Specimen 10. Label the container correctly, including
specimen type, test ordered, patient’s
Equipment and Supplies name and room number or address,
date and time, and physician’s name.
Bedpan with cover or specimen collector, Print required information on the cor-
stool-specimen container, tongue blades, rect lab requisition or obtain the requi-
label, disposable gloves, plastic waste bag, sition from your immediate supervisor.
biohazard bag, pen or pencil A lab requisition must be sent with the
labeled specimen.
Procedure 11. Put on gloves to clean the bedpan. Rinse
1. Check physician’s orders or obtain the bedpan with cool water. Clean with
authorization from your immediate a disinfectant, and rinse and dry. Replace
supervisor; verify the type of specimen all equipment used. Leave the area neat
needed. and clean.
2. Assemble equipment. 12. Remove gloves and wash hands.
3. Knock on the door and pause before 13. Keep the specimen warm. Put the speci-
entering. Introduce yourself. Identify men in a protective biohazard bag for
the patient. Explain the procedure to transport. Take or send it to the labora-
the patient. Ask the patient to use the tory immediately. Report the arrival of
bedpan for his or her next bowel move- the specimen to laboratory personnel.
ment because a specimen is needed. NOTE: The specimen should be exam-
Ask the patient not to void or place toilet ined within 30 minutes for most accu-
tissue in the bedpan. Provide a plastic rate results.
waste bag for soiled toilet tissue. 14. Wash hands.
NOTE: In some agencies, specimen col- 15. Report and/or record all required infor-
lectors that fit directly under the toilet mation on the patient’s chart or the
seat are used (refer to figure 21-76). agency form, for example, date, time,
4. Wash hands. Put on disposable gloves. stool specimen collected and sent to
CAUTION: Wear gloves and observe laboratory, and your signature and title.
standard precautions when obtaining
stool specimens.
5. Obtain the specimen in the bedpan.
Allow the patient to wash his or her
hands. Practice
NOTE: Assist with the bedpan, as neces- Go to the workbook and use the
sary. evaluation sheet for 21:10D,
Collecting a Stool Specimen, to
6. Take the bedpan to the bathroom.
7. Use two tongue blades to remove the believe you have mastered this skill,
stool from the bedpan. Place the stool in sign the sheet and give it to your
the specimen container. Discard the instructor for further action.
tongue blades in the plastic waste bag.
oughly.
CAUTION: Avoid contaminating the listed on the evaluation sheet, your
outside of the container. instructor will grade your performance.
PROCEDURE 21:10E
7. Place a paper towel on the counter. Put
Preparing and Testing the Hemoccult slide packet on top of
a Hemoccult Slide the towel.
8. Open the front cover or flap of the
NOTE: Legal requirements regarding
Hemoccult packet.
who can perform this procedure vary
from state to state. Check your legal 9. Use the tongue blade to smear a small
responsibilities before performing this amount of the stool specimen on the
procedure. correct areas of the slide (refer to figure
21-79). Use different parts of the stool
Equipment and Supplies specimen to obtain sample smears for
each of the two areas.
Bedpan with cover/specimen collector,
Hemoccult slide packet, Hemoccult devel- NOTE: Read the instructions. One or
oper, tongue blade, paper towel, disposable two small areas of exposed guaiac paper
gloves, plastic waste bag, biohazard bag, pen are present under the cover. Stool is
or pencil placed on these areas.
10. Discard the tongue blade in a plastic
Procedure waste bag.
11. Remove gloves and wash hands.
1. Obtain proper authorization to be sure
of the type of specimen needed. 12. Close the cover or flap of the Hemoccult
2. Assemble equipment. Read the manu- packet.
facturer’s instructions for the use of the 13. Label the outside of the Hemoccult
Hemoccult slide packet and developer. packet with all required information,
3. Knock on the door and pause before usually the date and time, patient’s
entering. Introduce yourself. Identify name and address or room number, and
the patient. Explain the procedure to physician’s name (figure 21-83A). Print
the patient. Ask the patient to use the required information on the correct lab
bedpan for his or her next bowel move- requisition or obtain the requisition
ment because a specimen is needed. from your immediate supervisor. A lab
Tell the patient not to void or place toilet
tissue in the specimen in the bedpan. If
necessary, provide a plastic waste bag
for disposal of soiled toilet tissue.
NOTE: In some agencies, specimen col-
lectors that fit directly under the toilet
seat are used (refer to figure 21-76).
standard precautions when obtaining
stool specimens.
5. Obtain the specimen in the bedpan.
Assist the patient, as necessary. Allow
the patient to wash his or her hands.
6. Take the bedpan and specimen to the FIGURE 21-83A Label the Hemoccult packet
bathroom. with all required information.
888 CHAPTER 21
PROCEDURE 21:10E
requisition must be sent with the labeled READING AND INTERPRETING THE HEMOCCULT ® TEST
specimen.
Negative Smears
14. Send the Hemoccult packet to the labo- Sample report: negative
No detectable blue on or at the edge of
ratory for developing. Put the specimen the smears indicates the test is negative
for occult blood.
in a protective biohazard bag for trans-
port. In some agencies, you may be
required to complete the test. To develop
the test, proceed as follows: Negative and Positive Smears Positive Smears
a. Wash hands and put on gloves.

b. Open the back tab of the Hemoccult
packet to expose the back of the Sample report: positive
guaiac paper. Any trace of blue on or at the edge of one or more of the smears indicates the test is
positive for occult blood.
c. Place the required number of drops FIGURE 21-83C A change in color indicates that
(usually one to two) of Hemoccult blood is present in the stool.
developer on the exposed guaiac
paper (figure 21-83B). Some packets f. Remove gloves and wash hands.
also have test areas to which devel- 15. Put on gloves to clean the bedpan. Dis-
oper is applied. card any remaining stool in the toilet.
NOTE: Read and follow manufacturer’s Rinse the bedpan with cool water. Clean
instructions. with a disinfectant, then rinse and dry.
Replace all equipment used. Leave the
d. Wait the correct amount of time, usu- area neat and clean.
ally 30–60 seconds.
e. Check the areas for color change. A
positive test usually causes a blue or 17. Report and/or record all required infor-
purple discoloration of the smear mation on the patient’s chart or the
(figure 21-83C). agency form, for example, date, time,
Hemoccult stool specimen obtained
NOTE: A positive test indicates the pres- and sent to laboratory, and your signa-
ence of blood in the stool. ture and title.
Practice
Preparing and Testing a Hemoccult
Slide, to practice this procedure.
further action.
FIGURE 21-83B Place the required number Final Checkpoint Using the criteria
of drops of Hemoccult developing solution on listed on the evaluation sheet, your
the exposed guaiac paper. instructor will grade your performance.
quently as tapwater or normal saline enemas.

21:11 INFORMATION Normal saline is usually the preferred solution
because it is an isotonic solution. It is the
Enemas and Rectal Treatments same concentration as body fluids and, there-
NOTE: Responsibility for performing these fore, does not cause fluid imbalances. A large
procedures varies from agency to agency. amount of the solution, from 750–1,000 milli-
Check your agency’s policy. liters (mL), is usually given. The main purpose
is to remove stool and flatus.
As a health care worker, you may be required ♦ Disposable enema: This is also a cleansing
to perform a number of rectal treatments. Equip- enema, in most cases. However, these enemas
ment and solutions will vary from agency to come in prepared, disposable containers, each
agency, but the same basic principles are fol- containing 4–6 ounces (120–180 mL). The
lowed. solution tends to be hypertonic, meaning that
An enema is an injection of fluid into the it draws fluid from the body to stimulate peri-
large intestine and through the rectum. The main stalsis and elimination of stool and flatus.
purpose of an enema is to remove feces and fla- ♦ Oil-retention enema: Mineral or olive oil may
tus (gas) from the colon and rectum. In addition, be used. Commercially prepared enemas con-
enemas can be used to relieve intestinal conges- taining oil are also available. Four to six ounces
tion and give medication. Before some surgeries, is the usual amount. These enemas are retained
imaging procedures, and childbirth, enemas may for at least 30–60 minutes. The main purpose
be ordered to clear the bowel of fecal material. is to soften fecal material so that it can be
The order may state, “enemas until clear.” This expelled. An oil-retention enema is sometimes
means that enemas are given until the return followed with a cleansing enema.
solution is the same as that injected, and no fecal
material is present. Check with your immediate The patient receiving an enema is usually
supervisor to determine how many enemas can placed in the Sims’ (left lateral) position. This
be given. encourages the solution to flow from the rectum
A physician’s order is required. The order usu- to the sigmoid portion of the colon. The patient
ally states the type of enema and the amount should be encouraged to breathe deeply during
of solution; it may also give other information such enema administration. Deep breathing encour-
as time, purpose, or special instructions. ages relaxation and increases retention of the
Enemas are frequently classified as retention solution for more effective results.
or nonretention enemas: Results must be observed after an enema is
given. Amount, type, and color of stool,
♦ Retention enemas are small amounts of solu- and/or the amount of flatus expelled should be
tion that are retained, or kept, in the intestine recorded.
for a specified period of time after they are An impaction is a large, hard mass of fecal
given. They are used to instill medications, material lodged in the intestine or rectum. Oil-
soften stool, aid in elimination of intestinal retention enemas are frequently ordered to soften
parasites, lubricate the rectum, or expel flatus. the impaction so it can be expelled. If it cannot be
♦ Nonretention enemas are usually expelled in removed by an enema, it is sometimes necessary
5–10 minutes. Larger quantities of solution are to insert a lubricated, gloved finger into the rec-
usually given, and the enemas are generally tum to break up the fecal material. The licensed
used to clean the bowel of feces and flatus supervisor or advanced care provider usually
(gas). performs this procedure.
Gas (flatus) accumulation in the intestine is a
Types of enemas in frequent use are cleans- frequent problem for surgical patients. A rectal
ing enemas, disposable enemas, and oil-reten- tube may be inserted to aid in the expulsion of
tion enemas. flatus. The tube is usually left in place for 20–30
♦ Cleansing enema: This is usually a soap- minutes. Because fecal material may drain out of
solution, tap-water enema, or normal saline the tube, it is wise to place the open end of the
solution. Soap-solution enemas irritate the tube in a basin or container. This procedure also
intestine, so they are no longer used as fre- is ordered by the physician.
890 CHAPTER 21
A suppository is a cone-shaped object that enemas and rectal treatments. Gloves must be
usually has a base material of cocoa butter worn. Hands must be washed frequently and are
or glycerine. It is inserted into the rectum and always washed immediately when gloves are
melts as a result of body heat. Suppositories are removed. Eye protection must be worn if spray-
used to stimulate peristalsis and aid in expelling ing or splashing of body fluids is possible.
feces. Medicated suppositories have medication Any areas or equipment contaminated by fecal
added to the base material. They can be used to material must be cleaned with a disinfectant or
relieve pain, decrease body temperature (aspirin sterilized. Most agencies use disposable enema
suppositories), stop vomiting (antiemetics), and kits and rectal tubes. These are discarded in an
treat other conditions, depending on the medica- infectious-waste bag after use. Precautions must
tion given. A health care worker is not permitted be taken at all times to prevent the spread of
to administer medications, so insertion of the infection.
medicated suppositories would not be your
responsibility. STUDENT: Go to the workbook and complete
Feces is contaminated with many microor- the assignment sheet for 21:11, Enemas and Rectal
ganisms, so standard precautions (discussed Treatments. Then return and continue with the
in Chapter 14:4) must be observed when giving procedures.
PROCEDURE 21:11A
4. Prepare the tray in the utility room or
Giving a Tap-Water, bathroom.
Normal Saline, or 5. If necessary, attach the tubing to the irri-
Soap-Solution Enema gation container or bag (figure 21-84A).
Adjust the clamp to the proper position
Equipment and Supplies on the tubing (figure 21-84B). Snap the
clamp shut.
Disposable enema kit (or irrigation container NOTE: If the tubing does not have a rec-
or bag with tubing, rectal tube, and liquid soap tal tube tip, attach a rectal tube.
for a soap-solution enema), graduated pitcher,
bath thermometer, paper towels, lubricating 6. Fill the irrigation container with tap
jelly, tray, two towels, toilet tissue, bedpan with water (or normal saline if ordered) to the
cover, bath blanket, underpad or bed protec- 1,000-milliliter (mL) line or to the level
tor, disposable gloves, basin, washcloth, soap, ordered by the physician, (figure 21-84C).
infectious-waste bag, pen or pencil Use a bath thermometer to check the
temperature of the water; it should mea-
Procedure sure 105°F or 41°C (figure 21-84D).
CAUTION: Be sure the temperature is
1. Check physician’s orders or obtain accurate. If the solution is too hot, it will
authorization from your immediate burn the mucous membrane of the
supervisor. patient. If it is too cold, it could cause
NOTE: The physician’s order usually cramps and discomfort.
states the type of enema and amount to
NOTE: If the irrigation container does
be given.
not have measurement markings, use a
2. Assemble equipment. graduated pitcher to measure the
3. Wash hands. amount needed. Then pour the solution
into the irrigation container or bag.
standard precautions when giving an NOTE: Water is used for a tap-water or
enema. soap-solution enema. Prepared normal
PROCEDURE 21:11A
FIGURE 21-84A Attach the FIGURE 21-84B Slip the FIGURE 21-84C Fill the
tubing to the enema con- clamp into position on the tubing, container with water to the
tainer. and snap the clamp shut. 1,000-milliliter (mL) line or the
level ordered by the physician.
FIGURE 21-84D Use a FIGURE 21-84E Add the FIGURE 21-84F Run the
bath thermometer to check packet of soap to the container, if solution through the tubing to
the temperature of the water; a soap-solution enema is remove air from the tubing.
it must measure 105°F. ordered.
saline (NS) solution is used for an NS
enema.
7. Put the packet of liquid soap into the
water if a soap-solution enema is
ordered (figure 21-84E). Stir gently to
prevent sud formation.
NOTE: If a packet of soap is not pro-
vided, usually 20–30 mL of castile soap
are added to the water. Soap is not added
to the solution for a tap-water or NS
enema.
8. Run the solution through the tubing to
FIGURE 21-84G Clamp remove air from the tubing (figure
the tubing. 21-84F). Clamp the tubing closed (figure
21-84G).
892 CHAPTER 21
PROCEDURE 21:11A
NOTE: This step can also be done imme- your immediate supervisor if you do not
diately before insertion of the enema. know which position to use.
9. Place a small amount of lubricant on a 19. Check to be sure the tip is lubricated.
paper towel. Place the tip of the tubing Loosen the clamp and let some solution
into the towel. flow through the tubing and into the
bedpan. Clamp off but make sure the
NOTE: Even prelubricated tips usually
solution is at the end of the tubing.
require additional lubrication.
20. Use one hand to raise the upper buttock
10. Place all equipment on the tray. Check
and expose the anus (the opening to the
to be sure all equipment is there. Cover
rectum). With your other hand, gently
the tray with a towel.
insert the tip 2–4 inches (5–10 centime-
11. Take the tray to the patient’s unit. ters) into the rectum (figure 21-85A). Tell
12. Knock on the door and pause before the patient you are inserting the tube.
entering. Introduce yourself. Identify Encourage deep breathing and relax-
the patient. Explain the procedure to ation.
the patient. Close the door and screen NOTE: If unable to insert the tube, pull
the unit. back slightly and attempt to reinsert. If
13. Wash hands. Put on gloves. still unable to insert, discontinue the
procedure and check with your imme-
CAUTION: Observe standard precau- diate supervisor. A fecal impaction may
tions when giving an enema. be present.
14. Place a chair by the bed and cover it with 21. Open the clamp. Raise the irrigation
an underpad or bed protector. Then container or bag 12 inches (30 centime-
place the bedpan on it. Position all ters) above the level of the anus (figure
equipment conveniently. 21-85B). Make sure the solution flows in
15. Elevate the bed to a comfortable work- slowly. Encourage the patient to breathe
ing height. Lower the siderail on the side deeply.
where you are working. NOTE: If the patient complains of
16. Cover the patient with a bath blanket. cramping or discomfort, clamp the tube
Fanfold the top bed linens to the foot of
the bed.
17. Place an underpad or bed protector
under the patient’s buttocks.
CAUTION: Use correct body mechanics.
Bend at the hips and maintain a wide
base of support.
18. Position the patient in the Sims’ (left lat-
eral) position. Fold the bath blanket
back at an angle to expose the buttocks.
NOTE: For patients who have difficulty
retaining the enema, it is permissible to
position them on the bedpan and in the
dorsal recumbent position. Check with
FIGURE 21-85A Use one hand to raise the
upper buttock and the other hand to gently
insert the tip 2–4 inches into the rectum.
PROCEDURE 21:11A
Leave the call signal and toilet tissue
within easy reach of the patient.
26. If the patient can be left alone, take the
equipment to the bathroom for clean-
ing; if not, remain with the patient.
Observe for signs of distress, weakness,
excessive perspiration, paleness, or dis-
comfort.
28. Answer the call signal immediately. Put
on gloves. Remove the bedpan. Assist
with cleaning the rectal area, if neces-
sary. Assist with perineal care as
FIGURE 21-85B Raise the irrigation bag 12
inches above the level of the anus to allow the
needed.
solution to slowly flow into the rectum. 29. Remove gloves. Provide a towel and
washcloth so that the patient can wash
his or her hands.
to stop the flow and wait until the 30. Reposition bed linens. Remove the bath
cramping stops. blanket and underpad or bed protector.
NOTE: Regulate the rate of flow by rais- 31. Observe all checkpoints before leaving
ing (for a faster flow) or lowering (for a the patient: position the patient com-
slower flow) the container or bag. The fortably and in correct body alignment,
container may also be placed on an elevate the siderails (if indicated), lower
adjustable IV pole or stand. the bed to its lowest level, place the call
22. When all of the solution has been signal and supplies within easy reach of
drained, clamp the tubing before air the patient, and leave the area neat and
enters the rectum. clean.
23. Remove the tubing gently. Tell the 32. Put on gloves. Take the bedpan to the
patient what you are doing. Wrap the bathroom. Observe contents before
tubing in tissue and place it in the empty emptying the bedpan. Note the amount,
irrigation container. type, and color of stool expelled, and the
effectiveness of the enema.
24. Position the patient on the bedpan as
previously instructed or escort the NOTE: Words such as good, poor, small,
patient to the bathroom or onto a bed- or no results are used to describe the
side commode, if the patient is ambula- effectiveness of an enema.
tory. Encourage the patient to retain the 33. Empty the bedpan. Rinse it with cold
enema as long as possible. If the patient water. Clean it with a disinfectant. Rinse,
is ambulatory and will use the toilet, dry, and return the bedpan to the
caution the patient not to flush the toi- patient’s unit.
let until results are noted.
34. Clean and replace all other equipment
NOTE: Retention yields more effective used. If the irrigation container is dis-
results. posable, place it in an infectious-waste
25. If the patient is on a bedpan, raise the bag.
patient’s head to a comfortable position.
894 CHAPTER 21
PROCEDURE 21:11A
oughly.
Practice
agency form; for example, date; time; evaluation sheet for 21:11A, Giving
1,000mL tap-water enema given with a TapWater, Normal Saline, or
good results, retained 10 minutes, Soap-Solution Enema, to practice
expelled four large dark-brown formed
stools, tolerated procedure well; and
unusual observations immediately.

PROCEDURE 21:11B
placing the tip in a paper towel with
Giving a Disposable lubricating jelly.
Enema NOTE: Even prelubricated tips often
need additional lubrication.
NOTE: Approximately 4 ounces (120 millili-
ters) of hypertonic solution is usually con- NOTE: If the enema is to be warmed,
tained in a plastic bottle with a prelubricated place it in a basin of water at a tempera-
tip (for example, a Fleet’s enema). ture of 105°F (41°C). Disposable enemas
are usually given at room temperature.
Equipment and Supplies 4. Place all equipment on the tray and
Disposable enema unit, lubricating jelly, cover with a towel. Go to the patient’s
paper towels, tray with cover, bath blanket, unit.
underpad or bed protector, bedpan with 5. Knock on the door and pause before
cover, toilet tissue, disposable gloves, basin, entering. Introduce yourself. Identify
towel, washcloth, soap, infectious-waste bag, the patient. Explain the procedure.
pen or pencil
6. Close the door and screen the unit.
Procedure 7. Wash hands. Put on gloves.
1. Check physician’s orders or obtain standard precautions when giving an
authorization from your immediate enema.
supervisor. Verify the type of enema.
8. Place a chair by the bed and cover it with
2. Assemble equipment. an underpad or bed protector. Then
3. Remove the enema from its package. place the bedpan on the chair. Position
Remove the cover from the tip. Add all equipment conveniently.
additional lubrication as needed by
PROCEDURE 21:11B
9. Elevate the bed to a comfortable work- manner. Hold the container at a slight
ing height. Lower the siderail on the side upward angle to prevent air bubbles.
of the bed where you are working. Encourage the patient to breathe deeply
and to retain the enema solution.
Fanfold the top bed linens to the foot of 15. When the solution has been injected
the bed. Place an underpad or bed pro- and the container is empty, gently
tector under the patient’s buttocks. remove the tip from the rectum. Inform
the patient as you do this. Place the con-
11. Position the patient in the Sims’ posi-
tainer in an infectious-waste bag.
tion. Fold the bath blanket at an angle to
expose the buttocks. 16. Place the bedpan under the patient or
assist the patient to the bathroom or
12. Squeeze the container slightly to get the
onto a bedside commode. Encourage
solution to the top of the tip and elimi-
5–10 minutes of retention.
nate air in the container (figure 21-86).
17. If the patient is on a bedpan, position
13. Use one hand to raise the upper buttock
the patient comfortably. Elevate the
and expose the anus (the opening to the
head of the bed. Leave the call signal
rectum). With your other hand, gently
and toilet tissue within easy reach of the
insert the tip approximately 2 inches (5
patient. Wash hands and remove gloves
centimeters). Explain each step to the
before leaving the room.
patient to reduce anxiety and apprehen-
sion. Ask the patient to breathe deeply NOTE: Remain with the patient, if nec-
while the tip is being inserted. essary.
NOTE: If unable to insert the tip, pull it 18. Answer the call signal immediately.
back slightly and try again. Sometimes, Wash hands and put on gloves. Remove
releasing a small amount of solution the bedpan. Assist the patient in clean-
eases insertion. If still unable to insert, ing the anal area, as needed. Assist with
discontinue the procedure and check perineal care as needed.
with your immediate supervisor.
19. Remove gloves and wash hands. Provide
14. To expel the solution, gently squeeze the a washcloth and towel. Allow the patient
container, starting from the bottom and to wash his or her hands with soap and
progressing toward the tip in a spiral water.
20. Replace the top bed linens. Remove the
bed protector and bath blanket. Posi-
tion the patient comfortably and in cor-
rect body alignment.
cated), lower the bed to its lowest level,
easy reach of the patient, and leave the
bathroom. Observe the contents of the
FIGURE 21-86 Squeeze the container bedpan before emptying. Note amount,
slightly to get the solution to the top of the tip of color, type, and any abnormalities.
a disposable enema.
896 CHAPTER 21
PROCEDURE 21:11B
Record the results or effectiveness of the
enema.
23. Empty the bedpan and rinse it with cold
water. Clean it with a disinfectant. Rinse,
Practice
dry, and return the bedpan to the evaluation sheet for 21:11B, Giving
patient’s unit. a Disposable Enema, to practice this
24. Clean and replace other equipment procedure. When you believe you
used. have mastered this skill, sign the
25. Remove gloves. Wash hands. sheet and give it to your instructor
for further action.
Fleet’s enema given with poor results,
expelled one small formed dark-brown
stool, patient complaining of “gas
pains”; and your signature and title. Final Checkpoint Using the criteria
Report any unusual observations imme- listed on the evaluation sheet, your
diately. instructor will grade your performance.
PROCEDURE 21:11C
3. If a commercial enema unit is used,
Giving an Oil- remove the enema from the outer pack-
Retention Enema age. Remove the protective cap from the
tip and add lubrication as needed by
Equipment and Supplies rolling the tip in a paper towel with
lubricating jelly.
Commercially prepared oil-retention enema
NOTE: If a commercial unit is not used,
(or 4–6 ounces mineral oil, olive oil, or other
use 4–6 ounces of mineral oil, olive oil,
oil specified by physician; irrigation container
or other oil specified in the order. Warm
with tubing, rectal tube, and clamp), lubricat-
the oil by placing the container in a pan
ing jelly, paper towels, disposable gloves, tray
of warm water. Measure the correct
with cover, bath blanket, underpad(s) or bed
amount of oil and place it in the irriga-
protector(s), toilet tissue, bedpan with cover,
tion container. Make sure the tubing is
basin, towel, washcloth, infectious-waste
free of air and the clamp is shut. Lubri-
bag, pen or pencil
cate the tip of the rectal tube.
Procedure 4. Place all equipment on a tray. Cover and
take to the patient’s unit.
1. Check physician’s orders or obtain 5. Knock on the door and pause before
authorization from your immediate entering. Introduce yourself. Identify
supervisor. Verify the type and amount the patient. Explain the procedure.
of enema.
PROCEDURE 21:11C
7. Wash hands. Put on gloves. 14. Squeeze the container in a spiral fash-
ion to expel the solution. Instill the solu-
tion slowly and gently. Encourage the
standard precautions when giving an
patient to breathe deeply and to retain
enema.
the enema solution.
8. Place a chair by the bed and cover it with
NOTE: If a container and tubing are
an underpad or bed protector. Then
used, raise the container 12 inches to
place the bedpan on the chair. Position
control the flow rate.
all equipment conveniently.
15. When the container is empty, gently
remove the tip. Tell the patient what you
are doing. Place the container in an
16. Encourage the patient to retain the solu-
Fanfold the top bed linens to the foot of
tion for at least 30–60 minutes. Leave
the bed. Place an underpad or bed pro-
the call signal within easy reach. Remove
tector under the patient’s buttocks.
gloves and wash hands thoroughly.
11. Position the patient in the Sims’ posi-
NOTE: If the oil seeps, an additional
tion (figure 21-87). Fold the bath blan-
underpad may be necessary.
ket at an angle to expose the buttocks.
17. Answer the call signal immediately.
12. Squeeze the container slightly to bring
Wash hands and put on gloves. Position
the oil to the tip and remove air.
the patient on the bedpan or assist him
NOTE: If an irrigation container and or her to the bathroom or onto a bed-
tubing are used, open the clamp to allow side commode. Make sure toilet tissue
oil to fill the tubing. and the call signal are within easy
13. Use one hand to raise the upper buttock reach.
and expose the anus (the opening to the NOTE: Remain with the patient, if nec-
rectum). With your other hand, gently essary.
insert the tip 2 inches into the rectum.
18. Answer the call signal immediately.
Tell the patient what you are doing.
Remove the bedpan. Assist the patient
in cleaning the anal area, as needed.
Assist with perineal care as needed.
NOTE: A tap-water or soap-solution
enema is sometimes ordered to follow
an oil-retention enema, if the results are
poor or the patient cannot expel the oil-
retention enema.
19. Remove gloves and wash hands. Provide
a washcloth and towel for the patient to
wash his or her hands.
20. Position the patient comfortably and in
correct body alignment. Replace top
FIGURE 21-87 Position the patient in a Sims’ bed linens. Remove underpad and bath
(left lateral) position with the right leg sharply blanket. If necessary, put a clean under-
flexed. pad under the patient’s buttocks.
898 CHAPTER 21
PROCEDURE 21:11C
NOTE: Because some oil may continue agency form; for example, date; time;
to seep from the rectum after cleaning, oil-retention enema given with good
it is usually wise to place a clean under- results, retained 30 minutes, expelled
pad under the patient’s buttocks. large amount of light brown semi-
formed stool and flatus, patient stated,
“I feel much better”; and your signature
and title. Report any abnormal observa-
tions immediately.
bathroom. Note amount, color, and type Practice
of stool before emptying. Go to the workbook and use the
evaluation sheet for 21:11C, Giving
23. Empty the bedpan and rinse it with cold
an Oil Retention Enema, to practice
water. Clean with a disinfectant. Rinse,
dry, and return the bedpan to the
patient’s unit.
24. Clean and replace all other equipment instructor for further action.
used.
26. Report and/or record all required infor- listed on the evaluation sheet, your
mation on the patient’s chart or the instructor will grade your performance.
PROCEDURE 21:11D
hour after administration of a medica-
Inserting a Rectal Tube tion.
2. Assemble equipment. Place the tip of
Equipment and Supplies the rectal tube in lubricating jelly on a
Rectal tube and flatus bag, lubricating jelly, paper towel. Connect the opposite
paper towel, tissue, underpad or protective (open) end to the flatus bag (figure
bed cover, basin or specimen bottle (if 21-88).
needed), disposable gloves, tape, infectious- NOTE: Instead of connecting it to a fla-
waste bag, pen or pencil tus bag, the open end may be placed in
a disposable glove and taped or in a
Procedure basin or specimen bottle. Follow agency
policy.
authorization from your immediate NOTE: Many agencies now use dispos-
supervisor. Note time ordered. able rectal tubes with flatus bags
attached. The tip of the tube must still
NOTE: This procedure may be ordered be lubricated. The tube and bag are dis-
for a specific time, for example, a half
PROCEDURE 21:11D
NOTE: Fecal material may seep from
tube.
11. Make sure the patient is as comfortable
as possible before leaving. Elevate side-
rails, if indicated. Leave the call signal
within easy reach of the patient.
oughly.
13. Return at intervals to check the patient
and rectal tube.
FIGURE 21-88 Place the tip of the rectal tube CAUTION: Do not leave if the patient is
in lubricating jelly on a paper towel. Connect the unconscious or not alert to surround-
opposite end to the flatus bag. ings.
14. Wash hands and put on gloves. Remove
carded in an infectious-waste bag after
the tube promptly at the end of the time
one use.
period, usually 20–30 minutes. Tell the
3. Knock on the door and pause before patient what you are doing. Remove the
entering. Introduce yourself. Identify tube gently.
CAUTION: The tube can irritate sensi-
the patient.
tive tissue if left in place too long.
15. Place the rectal tube and bag in the
5. Wash hands. Put on gloves. infectious-waste bag. Clean the patient,
CAUTION: Wear gloves and observe as needed. Remove the underpad and
standard precautions when giving an replace the bed linens.
enema. 16. Ask the patient how much flatus (gas)
6. Elevate the bed to a comfortable work- was expelled or if the patient feels
ing height. Lower the siderail on the side better.
where you are working. NOTE: Licensed personnel may listen to
7. Position the patient in the Sims’ posi- bowel sounds immediately after the rec-
tion. Place an underpad under the tal tube is removed. Inform the correct
patient’s buttocks. Fold the bed linen at person that you have removed the rectal
an angle to expose the buttocks. tube.
8. Use one hand to raise the upper buttock 17. Observe all checkpoints before leaving
and expose the anus (the opening to the the patient: position the patient in cor-
rectum). With your other hand, insert rect body alignment, elevate the side-
the rectal tube 2–4 inches into the rec- rails (if indicated), lower the bed to its
tum. Tell the patient what you are lowest level, place the call signal and
doing. supplies within easy reach of the patient,
9. Tape the tube to the patient’s buttocks
to hold the tube in place. 18. Note any result including collection of
air (flatus) in the bag, drainage, and
10. If a flatus bag is not in use, place the free patient’s comments following the pro-
end of the tube in a basin, bedpan, or cedure.
specimen bottle.
900 CHAPTER 21
PROCEDURE 21:11D
21. Report and/or record all required infor- Practice
mation on the patient’s chart or the Go to the workbook and use the
agency form; for example, date; time; evaluation sheet for 21:11D,
rectal tube inserted for 20 minutes, Inserting a Rectal Tube, to practice
expelled large amount of flatus, no this procedure. When you believe
drainage noted, Patient stated, “I feel you have mastered this skill, sign
much better”; and your signature and the sheet and give it to your
title. Report any unusual observations instructor for further action.
immediately.

the order must state the type of restraint, the rea-

21:12 INFORMATION son for its use, the length of time it can be used,
and where or when it can be used. The least
Applying Restraints restrictive device must always be used first. A
Although sick people are usually quiet and restraint applied unnecessarily can be consid-
need encouragement to move, there are ered false imprisonment. A health care worker
times when it is necessary to limit the movement should never apply a restraint without proper
of overactive patients. Restraints are used to authorization.
limit movement. There are two kinds of restraints: Circumstances and conditions that may
chemical and physical. Chemical restraints are necessitate the use of restraints include:
medications that affect the patient’s behavior.
Examples include tranquilizers, sedatives, and ♦ Irrational or confused patients: Patients can
mood-altering medications. Licensed personnel become irrational or confused because of
are responsible for administering any chemical medications, senility, and other factors. They
restraints. may attempt to climb out of bed or over side-
Physical restraints are protective devices rails, or may wander about. Because they
that limit a patient’s movements. They could fall and injure themselves, restraints
should be used only to protect patients from must sometimes be applied to limit their
harming themselves or others and when all other movements.
measures to correct the situation have failed.
♦ Skin conditions: Patients, especially small
Omnibus Budget Reconcilation Act (OBRA) legis-
children, with itching skin conditions must
lation clearly defines the limitations of using
sometimes have their hands restrained or
restraints. All resident behavior that may neces-
encased in protective mittens to prevent
sitate the use of restraints must be documented.
scratching.
Alternatives must be tried and carefully docu-
mented. If alternate solutions are not successful, ♦ Paralysis or limited muscular coordination:
the resident and/or resident’s family or legal Patients under anesthesia or who are para-
guardian must give approval and written consent lyzed by strokes are often unable to coordinate
for the use of a restraint or safety device. A physi- or control their muscular movements. They
cian must write the order for the restraint, and may require restraints.
There are different kinds of physical restraints. important to follow manufacturer’s directions
It is important to follow the manufacturer’s rec- and measure the patient carefully to make
ommendations when applying any kind of sure the correct size jacket restraint is used.
restraint. Some common kinds include: Jacket restraints must also be applied so that
they do not interfere with breathing or circu-
♦ Straps or safety belts: Usually found on wheel-
lation.
chairs, some are designed to be utilized
interchangeably on wheelchairs, beds, and ♦ Hand mitts: These devices are similar to mit-
stretchers (figure 21-89). A strap or safety belt tens that are applied to the hands to prevent
is used to prevent a patient from falling out of the patient from scratching or injuring the
the device. The strap or belt should not be skin (figure 21-90).
applied too tightly because it can restrict There are some important points to remem-
breathing and/or interfere with circulation. ber when using restraints:
♦ Limb restraints: Usually, soft, padded restraints ♦ Use only when all other means of obtaining
that are wrapped around the arm or leg to
the patient’s cooperation have failed.
limit movement of the limb. The restraint
straps are then attached to the movable part ♦ Restraints should be as unnoticeable to the
of the frame of the bed or stretcher to secure patient as possible.
the limb into position. At least two fingers ♦ Patients should be allowed to move as much
should be slipped between the restraint and as possible without danger of self-injury.
skin to make sure the restraint is not too ♦ The patient should always be told why his or
tight. her movements are being restricted, even
♦ Restraint jackets: These are used to prevent a when the patient is irrational or confused.
patient from sitting up, rolling, getting out of ♦ The restrained patient feels both physical and
bed, or falling out of a wheelchair. Jacket mental frustration. Therefore, it is important
restraints are available in different sizes. It is to reassure the patient frequently.
♦ Restraints should be checked frequently after
they have been applied. Circulation below a
limb restraint should be checked every 15–30
minutes. Signs of poor circulation include
paleness, cyanosis (blue discoloration), cold
skin, edema (swelling), weak or absent pulse,
poor return of pink color after the nail beds
are pressed lightly (or blanched), and the
patient complaining of pain, numbness, or
tingling. If any signs of poor circulation are
noted, the restraint must be removed immedi-
ately and your supervisor notified. All restraints
FIGURE 21-89 A belt restraint can be used to FIGURE 21-90 Hand mitts can be applied to
support a patient sitting in a wheelchair. (Courtesy prevent the patient from scratching or injuring the
of J.T. Posey Company) skin.
902 CHAPTER 21
must be removed every 2 hours for at least 10 ity to go to the bathroom at will can lead to
minutes. The patient should be repositioned, incontinence and constipation. Provide fre-
and range-of-motion (ROM) exercises and quent ROM exercises and offer to take the
skin care to the skin under the restraint should patient to the bathroom at regular intervals.
be provided. ♦ Respiratory or breathing problems, especially
♦ Remove restraints as soon as there is adequate when jacket restraints are applied, may
supervision or as soon as the danger of the develop.
patient injuring himself or herself has passed.
Most health care facilities have specific rules
Some complications that can occur when
and policies regarding the use of restraints.
restraints are applied include:
All patients have the right to maintain their dig-
♦ Physical and mental frustration on the part of nity and independence as much as possible. It is
the patient is common. The loss of freedom important for the staff to evaluate whether the
imposed by restraints can cause disorienta- risk for potential injury to the patient and/or oth-
tion, depression, hostility, agitation, and/or ers is greater than the risk for complications from
withdrawal. Provide reassurance and support- the use of restraints. It is essential that the health
ive care to the patient. care worker knows and follows all rules and poli-
♦ Impaired circulation can result. Check skin cies, and is aware of legal responsibilities regard-
color and skin temperature frequently. ing the use of restraints.
♦ Pressure ulcers from the pressure applied by
restraint can develop. STUDENT: Go to the workbook and complete
♦ Loss of muscle tone, joint stiffness, and discom- the assignment sheet for 21:12, Applying Restraints.
fort from immobility are common. The inabil- Then return and continue with the procedures.
PROCEDURE 21:12A
the patient. Explain the procedure even
Applying Limb if the patient is irrational or confused.
Restraints 4. Wash hands.
Equipment and Supplies 5. Close the door and screen the unit to
provide privacy. If the patient is in a bed,
Adjustable limb restraint(s), pen or pencil elevate the bed to a comfortable work-
ing height, and lower the siderail on the
Procedure side where you are working. If the
patient is in a wheelchair, lock the
1. Check physician’s orders or obtain wheels of the chair. Position the patient
authorization from your immediate in a comfortable position and in good
supervisor. body alignment.
CAUTION: A restraint cannot be applied 6. Place the soft edge of the restraint
without a physician’s order. against the patient’s skin (figure 21-91).
Wrap the restraint smoothly around the
NOTE: The order must state the type of
limb. Make sure there are no wrinkles.
restraint and reason for its use. The least
restrictive device must be used first. 7. Pull the ends of the straps through the
tabs or rings on the restraint. Then pull
the restraint secure, but not too tight,
3. Knock on the door and pause before against the patient’s skin.
PROCEDURE 21:12A
FIGURE 21-91 Place the soft edge of the

limb restraint against the patient’s skin. (Cour-
tesy of J.T. Posey Company)
CAUTION: If applied too tightly, the
restraint could stop circulation or cause
a pressure sore.
8. Test for fit and comfort by inserting two
fingers between the restraint and the
patient’s skin. FIGURE 21-92 Restraint straps must always be
tied to the movable part of the bed frame so the
9. Position the arm or leg in a comfortable restraints move when the bed moves.
position. Limit movement only as much
as is necessary.
rect body alignment, place the call sig-
10. Use a quick-release tie to secure the nal and supplies within easy reach of
straps to the movable part of the bed the patient, elevate the siderails (if indi-
frame, stretcher frame, or other frame cated), lower the bed to its lowest level,
(figure 21-92). To make the quick-release and leave the area neat and clean.
tie, bring the end of the strap around the
13. Check the circulation below the limb
frame. Then bring the loose end up
restraint every 15–30 minutes. Note
behind and around the back of the strap
color and temperature of skin, return of
to create a hole. Fold the loose end of
color after pressing lightly on nail beds,
the strap into a loop and tuck the loop
edema (or swelling), and patient com-
into the hole formed. Pull up on the
plaints of pain, numbness, or tingling.
descending part of the strap to tighten
the loop in the hole. To release the tie, CAUTION: If any signs of impaired cir-
simply pull on the loose, exposed end of culation are noted, remove the restraint
the strap. immediately and notify your super-
visor.
11. Recheck the patient before leaving.
14. Remove the restraint every 2 hours for at
CAUTION: Make sure the restraint is
least 10 minutes. Reposition the patient.
secure but not too tight.
Provide ROM exercises to the restrained
12. Observe all checkpoints before leaving limb. Administer skin care to the skin
the patient: position the patient in cor- under the restraint.
904 CHAPTER 21
PROCEDURE 21:12A
15. Remove the restraint when authorized
to do so by your supervisor or the physi-
cian.
NOTE: Restraints are removed when the
Practice
physician or supervisor feels that the evaluation sheet for 21:12A,
danger of self-injury to the patient has Applying Limb Restraints, to
passed. Restraints must always be practice this procedure. When you
removed as soon as is possible.
16. Replace all equipment. sign the sheet and give it to your
17. Wash hands. instructor for further action.

limb restraints applied to both arms
while patient positioned in wheelchair,
P 82 strong and regular at both wrists,
patient appears to be resting quietly; Final Checkpoint Using the criteria
and your signature and title. Report any listed on the evaluation sheet, your
unusual observations immediately. instructor will grade your performance.
PROCEDURE 21:12B
patient to make sure the correct size
Applying a Jacket jacket/vest restraint is used. If an incor-
Restraint rect size is used, the restraint will not
provide proper support and could injure
Equipment and Supplies the patient.
Sleeveless jacket restraint, pen or pencil
the patient. Explain the procedure even
Procedure if the patient is irrational or confused.
1. Check physician’s orders or obtain 4. Wash hands.
authorization from your immediate 5. Close the door and screen the unit to
supervisor. provide privacy. If the patient is in a bed,
CAUTION: A restraint cannot be applied elevate the bed to a comfortable work-
without a physician’s order. ing height, and lower the siderail on the
side where you are working. If the
NOTE: The order must state the type of
patient is in a wheelchair, lock the
restraint and reason for its use. The least
wheels of the chair. Position the patient
restrictive device must be used first.
in a comfortable position and in good
2. Assemble equipment. Obtain the cor- body alignment.
rect size restraint for the patient.
6. Slip the sleeves of the jacket restraint
CAUTION: Follow manufacturer’s onto the patient’s arms. The solid part of
instructions and carefully measure the the jacket restraint goes on the back, and
PROCEDURE 21:12B
the open or V-neck part of the restraint 10. Position the patient in a comfortable
goes on the front (figure 21-93A). It is position. Allow as much movement as
essential to follow manufacturer’s possible without risk for injury.
instructions.
11. On each side of a bed or stretcher, use a
CAUTION: A restraint applied incor- quick-release tie to bring the straps
rectly may cause suffocation or injury. down and secure them to the movable
part of the frame.
7. Crisscross the straps in the back. Check
all of the material to make sure it is free 12. Straps should be brought down between
from wrinkles. the wheelchair and side plate. In a
wheelchair, the straps can be attached
8. Bring the loose ends of the straps
to the kick bars at the rear of the wheel-
through the hole in the jacket. The jacket
chair. Note that the kick bars must have
should now completely encircle the
their plastic end-caps in place to ensure
patient.
that the ties will not slip off (figure
9. Check the restraint to be sure it is not 21-93B).
too tight against the patient.
CAUTION: Never attach the straps to
CAUTION: Excessive tightness could any parts of the wheels.
interfere with breathing.
13. Recheck the restraint before leaving the
patient. Check the patient’s respira-
tions.
the patient: position the patient com-
fortably and in correct body alignment,
FIGURE 21-93A Follow manufacturer’s

instructions to measure a patient to make sure
the jacket or vest is the correct size. Position the
jacket restraint with the open or V-neck part of FIGURE 21-93B Use a quick-release tie to
the restraint on the front. (Courtesy of J. T. secure the straps to the back frame of a wheel-
Posey Company) chair. (Courtesy of J. T. Posey Company)
906 CHAPTER 21
PROCEDURE 21:12B
easy reach of the patient, elevate the 18. Replace all equipment.
siderails (if indicated), lower the bed to
19. Wash hands.
its lowest level, and leave the area neat
and clean. 20. Report and/or record all required infor-
15. Return every 15–30 minutes to check
the patient. Check count and character
jacket restraint applied, patient seated
of respirations, and the color and tem-
in wheelchair; and your signature and
perature of the skin.
title.
CAUTION: If any signs of impaired cir-
culation or respiration are noted, remove
the restraint immediately and notify
your supervisor.
Practice
16. Remove the restraint every 2 hours for at Go to the workbook and use the
least 10 minutes. Reposition the patient. evaluation sheet for 21:12B,
Provide ROM exercises. Administer skin Applying a Jacket Restraint, to
care to the skin under the restraint. practice this procedure. When you
17. Remove the restraint when authorized believe you have mastered this skill,
to do so by your supervisor or the physi- sign the sheet and give it to your
cian. instructor for further action.
NOTE: A restraint is removed when the
danger of self-injury has passed. Final Checkpoint Using the criteria
Restraints must always be removed as listed on the evaluation sheet, your
soon as is possible. instructor will grade your performance.
21:13 INFORMATION ing disfigurement, pain, loss of control, the

unknown, length of recovery time, costs and
Administering Preoperative financial problems, a poor diagnosis after sur-
and Postoperative Care gery, and even death create concerns for many
patients. It is important to provide emotional
Providing care to patients scheduled for surgery support in addition to physical care. Answer all
may be one of your responsibilities as a health questions you can to the best of your ability. How-
care worker. Surgical care is divided into three ever, specific questions about the surgery, out-
phases: come, or anesthesia should be referred to the
♦ Preoperative care (pre-op): care provided physician or your supervisor. Be sure to report
before the surgery these questions and the patient’s fears to your
immediate supervisor.
♦ Operative care: care provided during the
surgery
♦ Postoperative care (post-op): care provided
following surgery
NOTE: Unless you work in an operating room,

PREOPERATIVE CARE
your major responsibilities will likely involve the Preoperative care involves many aspects of care.
pre-op and post-op phases. Most of the preparation is ordered by the physi-
Every patient scheduled for surgery, no mat- cian, depending on the type of operation. Possi-
ter how minor, has some fears. Fears regard- ble aspects of preparation are:
♦ Operative permit: This is a form signed the operating room. Skin preparation sites for
by the patient to give permission for the some specific surgeries are shown in figure
anesthesia and surgery. It must be witnessed 21-94. Each agency has its own policy regard-
by a legally authorized individual. ing what area is to be prepared. Sometimes,
the physician specifies the area. The skin is
♦ Laboratory tests: These tests may include shaved to prevent infection in and around the
blood tests, urine tests, chest or other radio-
surgical site, and to remove longer hair that
graphs, electrocardiogram (ECG), and special
would interfere with surgery.
tests ordered by the physician.
♦ Clothing: Usually, the patient must remove all
♦ Enemas or vaginal irrigations: These are clothing, including undergarments. A hospital
ordered by the physician in preparation for
gown is placed on the patient. Most agencies
certain types of surgery.
also place a surgical cap on the patient to
♦ Baths: Baths may be given both the night cover the hair.
before surgery and the morning of surgery.
♦ Name band: Prior to surgery, the patient’s
The purpose is to remove as many microor-
name band or identification band should
ganisms as possible in an effort to prevent
be checked for accurate information. Because
infections. It also gives the patient a chance to
the patient frequently is unconscious during
talk and relieve some anxiety.
surgery, the name band is the only method of
♦ Vital signs: These are taken and recorded. They identifying the patient.
are used as a standard to check vital signs dur-
♦ Voiding: To make sure the bladder is empty dur-
ing and after the surgery.
ing surgery, the patient should void immedi-
♦ NPO: The patient is allowed nothing by mouth ately before being brought to the operating
for 8–12 hours before the surgery. The order is room. For some surgeries, a catheter is inserted
usually started at 12:00 A.M. (midnight). A sign in the bladder to constantly drain all urine. Only
is usually placed on the patient’s bed. Water is a qualified person should insert the catheter.
removed from the area at the appointed time.
♦ Surgical checklist: Most agencies use surgical
♦ Valuables: All the patient’s valuables, includ- checklists to track most of the previously noted
ing money and jewelry, should be placed in a preparation items. As these items are com-
hospital safe to prevent loss. A patient is some- pleted, they are checked off the checklist. This
times allowed to wear a wedding ring. How- provides a method for determining that the
ever, it must be taped or tied to the finger to patient has been properly prepared for sur-
prevent loss. gery. The checklist is usually attached to the
♦ Remove prosthetics: All artificial parts are patient’s chart.
removed. This includes dentures, contact Frequently, patients are not admitted to the
lenses or glasses, artificial arms or legs, and hospital or surgical clinic until the morning of the
hearing aids. surgery. In this case, many of the tests such as
♦ Remove cosmetics: Nail polish, makeup, hair blood work, radiographs, and ECG are performed
pins, and wigs are all removed prior to surgery. on an outpatient basis.
Presence of cosmetics can mask skin or nail
bed color changes.
♦ Surgical shave or skin preparation: This ANESTHESIA
includes shaving and cleaning of the operative
Anesthesia is prevention of pain by way of loss of
site. This may or may not be done. Some phy-
sensation. Medication is administered by an anes-
sicians feel that shaving the skin can cause
thesiologist, anesthetist, or physician. The type of
superficial cuts that lead to infection, a con-
anesthetic used and the method of administration
cern supported by the Centers for Disease
depends on the type of surgery, the length of time
Control and Prevention (CDC). If a surgical
needed, and the physical condition of the patient.
shave is done, it can be done by a special skin-
Three main kinds are as follows:
prep team or by the surgical staff immediately
before the surgery or, sometimes, by the nurse ♦ General anesthesia: Medication is given intra-
assistant before the patient is transferred to venously or is inhaled through a mask. This
908 CHAPTER 21
Abdominal Anterior chest Posterior Back

surgery and surgery
breast surger y
Vaginal, rectal
and
perineal surgery
Kidney Left arm

surgery surgery
FIGURE 21-94 Shaded areas represent skin-preparation sites for some specific surgeries.
causes unconsciousness, which continues patient returns from surgery. A recovery bed is
throughout surgery. A common postoperative made, an intravenous (IV) pole or stand and
problem is nausea or vomiting. equipment for taking vital signs is put in place,
♦ Local anesthesia: Medication is injected into and an emesis basin and tissues are placed at the
the area around the operative site to stop the bedside. Necessary special equipment, such as a
sensation of pain. The patient is awake when suction machine for drainage tubes or equipment
local anesthesia is used. for administering oxygen, is also placed in the
unit. All unnecessary supplies or equipment are
♦ Spinal anesthesia: Medication is injected into removed from the area. For example, the water
the spinal canal and causes loss of sensation pitcher and cup are removed until postoperative
(feeling) in all areas below the injection. This orders state that the patient can have fluids.
is often used for abdominal surgery because it Postoperative care is an important aspect of
produces good muscle relaxation. Patients surgical care. Some of the factors to be consid-
must be told that they will not have any feel- ered in immediate postoperative care are:
ing or movement in the legs for a period of
time. Patients sometimes complain of head- ♦ Vital signs: These must be checked frequently
aches after this type of anesthesia. This symp- and as ordered. They are sometimes taken
tom should be reported. every 15 minutes until the patient is stable. A
sudden drop in blood pressure or change in
pulse rate or character are often the first signs
POSTOPERATIVE CARE of hemorrhage and/or shock, so any changes
or abnormal readings must be reported imme-
While the patient is in surgery, the postoperative diately.
room or bed unit is prepared in such a way that all ♦ Dressings: These must be checked frequently
necessary equipment will be available when the (figure 21-95). Color, amount, and type of
after general anesthesia (figure 21-96). This

exercise helps remove mucus from the lungs
and respiratory tract and helps prevent pneu-
monia and other lung disorders.
♦ Tubes: Surgical patients frequently have
drainage tubes in place. The tubes are
connected to drainage bottles or special drain-
age collectors. If the tubes are not draining, if
they are clamped, if the drainage solution
changes or seems unusual, if a tube is not con-
nected to a drainage source, or if any unusual
observations are noted, they should be
reported immediately. Care must also be taken
FIGURE 21-95 Dressings must be checked when turning or moving the patient to make
frequently after surgery. sure that the tubes are not disconnected,
twisted, or pulled out.
Binders are special devices that are ordered
drainage must be noted. Any unusual obser- to hold dressings in place or provide support.
vations should be reported immediately. (See Information section 21:14 for information
♦ IV: Flow rate and injection site must be checked about binders.)
only by an authorized individual. Surgical (elastic) hose may be ordered to
♦ Level of pain: An assessment must be made on support the veins of the legs and increase circula-
the amount of pain a patient is experiencing. tion. These hose help prevent formation of blood
Frequently patients are asked to describe pain clots in the legs. The hose must be applied cor-
on a scale of 1 to 10, with 1 being mild pain rectly. If they are applied too tightly, they can
and 10 being extreme pain. Patient-controlled interfere with circulation.
analgesics (PCAs) are often used to control Montgomery straps are special adhesive
pain. An analgesic pump is attached to an IV strips that are applied when dressings must be
line. The patient is taught to push a button changed frequently at the surgical site (figure
when pain is felt. The pump delivers a specific 21-97). The skin around the surgical site is cleaned
dose of pain medication directly into the thoroughly. A skin barrier, such as a liquid or
bloodstream to provide immediate relief. The paste, is applied to the skin to protect it from irri-
patient cannot overdose on the medication tation from the tape. The Montgomery straps are
because the pump locks out delivery of medi- then applied on either side of the surgical site.
cation for a set period of time. A change in
position, if allowed, can also help alleviate
pain. If patients do not seem to be able to get
pain relief, this should be reported immedi-
ately.
♦ Observations: Restlessness, color and temper-
ature of skin, nausea and/or vomiting, and
similar observations should be noted and
reported.
♦ Position: The patient’s position must be
changed when possible. Be sure you are aware
of all movement restrictions. Some operations
limit movement and positioning. Turn or move
patients only after obtaining correct authori-
zation. FIGURE 21-96 A pillow across the abdomen
♦ Cough and deep breathe: Most patients need provides support when the patient is coughing and
to be encouraged to cough and deep breathe deep breathing.
910 CHAPTER 21
The centers of the straps are nonadhesive and

tied together. To change dressings, the straps are
untied, the dressings are changed, and the straps
are then tied in place on top of the dressings. This
eliminates the need to remove and reapply adhe-
sive tape during each dressing change.
SUMMARY
It is essential that the nurse assistant follow
all standard precautions whenever contact
with blood or body fluids is possible. This helps
prevent the spread of infection, including infec-
tion in the surgical patient after surgery.
It is essential for the nurse assistant to know
and understand all aspects of care that have been
ordered to properly care for the surgical patient.
Good operative care can mean a faster recovery
with fewer complications for the patient.

FIGURE 21-97 Montgomery straps are special the assignment sheet for 21:13, Administering Pre-
adhesive strips that are applied when dressings operative and Postoperative Care. Then return
must be changed frequently at the surgical site. and continue with the procedures.
PROCEDURE 21:13A
NOTE: Sometimes, the physician orders
Shaving the what area is to be shaved; other times
Operative Area agency policy is followed.
NOTE: Disposable kits contain a bowl, razor,
and most of the other supplies. 3. Prepare equipment in the utility room
or bathroom. Fill both bowls (or sec-
Equipment and Supplies tions of the skin-preparation kit) with
water at 105°F, or 41°C. Add liquid
Skin-preparation kit, two bowls (if a kit is not cleansing soap to one bowl. Place the
used), razor and blades, ordered cleansing bowls on the tray.
soap, gauze sponges, paper towels, applica-
NOTE: Some kits contain sponges satu-
tor sticks, bath blanket, underpads or bed
rated with soap. Soap does not have to
protectors, washcloth, towel, tray with cover,
be added when using these kits.
disposable gloves, gooseneck light or good
light source, puncture-resistant sharps con- 4. Check razor and blades carefully. Care-
tainer, plastic waste bag, pen or pencil fully rub the blades over a folded gauze
pad to check for damaged edges. Make
Procedure sure there are no rough edges on the
blades.
1. Check physician’s orders or obtain CAUTION: Rough or damaged blades
authorization from your immediate can nick or cut the patient’s skin. Dis-
supervisor. Clarify any questions about card any defective blades.
the area to be shaved.
PROCEDURE 21:13A
5. Check the tray for all equipment and 16. If the abdominal area is shaved, clean
take it to the patient’s unit. the umbilicus (navel) with cotton-
6. Knock on the door and pause before tipped applicators. Shave with a circular
entering. Introduce yourself. Identify motion, if necessary.
the patient. Explain the procedure. 17. Carefully check the shaved area for any
7. Close the door and screen the unit. remaining hairs. Hold a light at an angle
to the skin to see reflections of any
8. Wash hands. remaining hairs. Remove all remaining
NOTE: Gloves may be put on at this hairs.
point or immediately before shaving the 18. Wash the area with warm soapy water.
patient. Rinse thoroughly and dry.
9. Elevate the bed to a comfortable work- 19. Replace the top bed linens and remove
ing height. Lower the siderail on the side the bath blanket and underpad.
where you are working. Cover the patient
with a bath blanket. Fanfold the top bed 20. Observe all checkpoints before leaving
linens to the foot of the bed. Place an the patient: position the patient in cor-
underpad near the area to be shaved. rect body alignment, elevate the side-
10. Position the gooseneck light or other lowest level, place the call signal and
light source so that the skin area is supplies within easy reach of the patient,
clearly illuminated. Make sure there are and leave the area neat and clean.
no glares or shadows.
21. Clean and replace all equipment. Put
11. Put on disposable gloves. the used blades or disposable razor(s) in
CAUTION: If you nick the skin, observe a puncture-resistant sharps container.
standard precautions while controlling 22. Remove gloves. Wash hands.
bleeding.
12. Start at the top of the area to be shaved. mation on the patient’s chart or the
Apply soapy lather to a small area of skin. agency form; for example, date; time;
13. Hold the skin taut. Shave in the direc- abdominal skin prep completed, patient
tion of hair growth. If the hair is long, as resting quietly; and your signature and
may be the case with pubic, axillary, or title. Report any cuts, nicks, or unusual
chest hair, it may be clipped with scis- observations immediately.
sors first. Take care to avoid cutting the
patient’s skin with the scissors.
NOTE: When scalp hair must be cut
before brain or skull surgery, it is usually Practice
done in the operating room because it Go to the workbook and use the
can be very traumatic for the patient. evaluation sheet for 21–13A,
CAUTION: Watch out for areas with Shaving the Operative Area, to
moles or warts. Shave carefully around practice this procedure. When you
these areas. believe you have mastered this skill,
14. Rinse the razor in the bowl of clean sign the sheet and give it to your
water. Remove excess hairs by rubbing instructor for further action.
the razor edge against a gauze square.
15. Repeat steps 12 to 14 on small areas until Final Checkpoint Using the criteria
the entire operative site has been shaved. listed on the evaluation sheet, your
Work from top to bottom, side to side. instructor will grade your performance.
912 CHAPTER 21
PROCEDURE 21:13B
10. Remove all hairpins, wigs, and other
Administering hair ornaments. Put a cap on the patient.
Preoperative Care Make sure all hair is inside the cap.
11. Remove nail polish. Check to be sure the
Equipment and Supplies patient is not wearing any makeup.
Thermometer, stethoscope and sphygmoma- 12. Remove all of the patient’s jewelry and
nometer, surgical gown and cap, nail polish place it in a valuables envelope. Also
remover, valuables envelope, tape or gauze (if place money and other valuables in the
needed), paper, pencil or pen envelope. Follow hospital procedure for
placing the valuables in a safe.
Procedure NOTE: Wedding rings may be tied or
taped in place. Follow hospital proce-
1. Check physician’s orders or obtain dure.
supervisor. Check the time of surgery. CAUTION: In some agencies, only cer-
tain health care workers are permitted
NOTE: Care should be completed 1 hour to handle valuables. Follow agency pol-
prior to surgery. icy.
2. Assemble equipment. 13. Remove full or partial dentures. Place
3. Knock on the door and pause before these in a denture cup labeled with the
entering. Introduce yourself. Identify patient’s name and room number. Place
the patient. Explain the procedure. the cup in a drawer or safe area to pre-
vent breakage.
NOTE: The patient may be frightened;
reassure as needed. 14. Have the patient remove contact lenses,
glasses, hearing aids, and all other pros-
theses (artificial parts). Place in a safe
5. Wash hands. area.
6. Elevate the bed to a comfortable work- 15. Offer a bedpan or assist the patient to
ing height. Lower the siderail on the side the bathroom. Encourage the patient to
where you are working. void. If a catheter and urinary-drainage
7. Check the patient’s identification band. unit is in place, empty the urinary-drain-
Make sure it is secure. Verify name, room age unit and record the measurement.
number, and other facts. 16. Take vital signs and record correctly (fig-
8. Assist with or instruct the patient to ure 21-98).
complete oral hygiene and bath. CAUTION: These must be accurate and
NOTE: The bed is not made prior to sur- correct. If in doubt about the results, ask
gery. your supervisor to check them.
CAUTION: Because the patient is NPO 17. Elevate the siderail immediately after
(nothing by mouth), do not allow the preoperative medication has been given
patient to swallow any water when per- by an authorized person.
forming oral hygiene. NOTE: Preoperative medication is usu-
9. Put a surgical gown on the patient. No ally given 1 hour before surgery. It helps
other clothing is permitted. Make sure the patient relax, and often contains
the patient’s underwear is removed. medication to dry up nose and mouth
PROCEDURE 21:13B
NOTE: Many hospitals use pre-op
checklists, which are placed on patients’
charts. If this is hospital policy, com-
plete the checklist.
21. Wash hands.
pre-op care complete and noted on
checklist, siderails elevated, patient
resting quietly; and your signature and
title. Report any unusual observations
FIGURE 21-98 Vital signs must be taken and immediately.
recorded as part of preoperative care.
secretions. Because the patient could

become drowsy and fall out of bed, the
siderails must be elevated immediately.
Practice
18. Place the patient in a comfortable posi- evaluation sheet for 21–13B,
tion. Encourage the patient to rest. Administering Preoperative Care, to
19. Observe all checkpoints before leaving practice this procedure. When you
the patient: make sure the water pitcher believe you have mastered this skill,
has been removed from the unit, lower sign the sheet and give it to your
the bed to its lowest level, place the call instructor for further action.
signal within easy reach of the patient,
PROCEDURE 21:13C
Preparing a Procedure
Postoperative Unit 1. Assemble equipment.
NOTE: The post-op unit is prepared
Equipment and Supplies immediately after the patient leaves the
Bed linen for an unoccupied bed; extra draw area for the operating room.
sheet; underpads or protective covers; emesis 2. Wash hands. Put on gloves if needed.
basin; tissues; plastic bag and tape; gauze
bandage; intravenous (IV) pole or stand; vital CAUTION: Wear gloves if the linen is
signs equipment (thermometer, blood pres- contaminated with blood, body fluids,
sure apparatus, watch with second hand); secretions, or excretions. Remove the
linen bag, hamper, or cart; pen or pencil gloves and wash hands thoroughly after
914 CHAPTER 21
PROCEDURE 21:13C
removing the dirty linen and before 13. Put a cuff on the plastic bag. Tape it to
applying the clean linen. the side of the bed or bedside table.
3. Remove any used linen from the bed and 14. Place underpads on the bed near where
place in the linen bag, hamper, or cart. the operated body part will be resting.
4. Make the foundation (bottom sheet and 15. Remove all unnecessary articles from
draw sheet) of the bed as previously the bedside stand. Place the emesis
instructed for an unoccupied bed. basin, tissues, and equipment for taking
vital signs on the stand.
5. Place a cotton draw sheet over the head
of the bed. Tuck in at the head of the bed NOTE: Make sure the water pitcher and
as was done for bottom sheet. Make cup are not on the bedside stand.
mitered corners and tuck in at the Patients may be NPO (nothing by
sides. mouth) postoperatively.
NOTE: This protects the bed should the 16. Position the overbed table, chair, and
patient vomit. other furniture so it will not be in the
way of the stretcher.
NOTE: Some agencies use underpads
instead of draw sheets. 17. Place the IV stand and/or pump in the
most convenient location. It should be
6. Place a top sheet and a spread on the
ready for the IV when the patient is
bed. Let them fall loose.
transferred to the bed.
7. Go to the foot of the bed and fold the top
18. Check the area before leaving. Make
linen back. Make a cuff so that the top
sure that all equipment and supplies are
linen is even with the end of the mat-
ready for the patient’s return from sur-
tress.
gery (figure 21-99).
NOTE: The top linen is not tucked in.
8. Go to the head of the bed. Make a cuff
with the top linen.
9. Fanfold the top linen to the side of the
bed opposite from where the patient
will be brought in on the stretcher.
NOTE: In some agencies, the sheets are
folded to the foot of the bed. Follow
agency policy.
10. Elevate the siderail on the far side of the
bed.
11. Cover the pillow with a pillowcase. Posi-
tion the pillow in an upright position at
the head of the bed. Use a gauze ban-
dage to tie it to the head of the bed.
NOTE: This protects the patient’s head
against injury during the transfer to the
bed.
FIGURE 21-99 Before leaving the post-op
unit, check to make sure that all equipment and
12. Estimate the height of the stretcher and supplies are ready for the patient’s return from
elevate the bed to this height. surgery.
PROCEDURE 21:13C
20. Wash hands.
Practice
post-op unit prepared, and your signa- evaluation sheet for 21–13C,
ture and title. Preparing a Postoperative Unit, to
PROCEDURE 21:13D
came with the hose to determine the
Applying Surgical correct size for the patient.
Hose 6. Close the door and screen the unit. Ele-
vate the bed to a comfortable working
NOTE: Surgical hose come in various sizes
and lengths. This procedure deals with
where you are working. Expose the
the application of knee-length surgical
patient’s legs.
stockings.
7. Insert your hand into the top of the hose.
Equipment and Supplies Turn the hose so that the smooth side is
on the outside.
Correct size surgical hose, measuring tape,
pen or pencil NOTE: This makes application easier
and leaves the rough edge on the out-
Procedure side of the foot.
8. Grasp the heel area of the hose. Smoothly
1. Check physician’s orders or obtain tuck the foot portion back into the stock-
authorization from your immediate ing.
supervisor.
9. Stretch the hose open at the heel. Sup-
2. Assemble equipment. port the patient’s leg and slide the foot
3. Knock on the door and pause before and pocket of the heel into position on
entering. Introduce yourself. Identify the patient’s foot (figure 21-100A).
the patient. Explain the procedure. CAUTION: Use correct body mechanics
4. Wash hands. when applying hose. Stand with your
feet apart and one leg ahead of the other,
5. Check the hose to be sure they are clean
bending at the hips rather than the
and the correct size.
waist.
NOTE: Hose from different companies
10. Make sure the heel of the stocking is
are sized differently. Use the measuring
secure over the patient’s heel.
tape and follow the instructions that
916 CHAPTER 21
PROCEDURE 21:13D
FIGURE 21-100A Slide the foot of the hose

into position.
11. Grasp the top of the stocking. Pull it over FIGURE 21-100C Pull the toe forward
slightly to provide “toe room.”
the foot. Gather the material at the ankle.
Use two hands and gentle pressure. supplies within easy reach of the patient,
12. Begin gently pulling the hose up the leg
to the area below the knee (figure 21- 17. Check the hose at intervals. Look for signs
100B). Work slowly to prevent wrinkles. of impaired circulation, including abnor-
Use both hands to smooth the hose into mal skin color or temperature, swelling,
place. and other abnormalities. Report any
abnormalities to your supervisor imme-
CAUTION: Do not pull and stretch the diately. Remove the hose at intervals, at
hose. This will make it too tight and least once every 8 hours. Administer skin
interfere with circulation. care to the skin under the hose. If the hose
13. Check the position of the hose. The top become soiled, they can be washed.
should be just below the knee. Smooth 18. Wash hands.
any excess material with your hands.
14. Pull the toe forward slightly to provide mation on the patient’s chart or the
“toe room” (figure 21-100C). agency form, for example, date, time,
15. Repeat steps 7 to 14 for the opposite leg. surgical hose applied to both legs, and
lowest level, place the call signal and
Practice
Applying Surgical Hose, to practice

FIGURE 21-100B Draw the hose gently up listed on the evaluation sheet, your
the leg to the area below the knee. instructor will grade your performance.
21:14 INFORMATION
Applying Binders
Binders are usually made of heavy cotton or
flannelette with elastic sides or supports. They
are applied to various parts of the body, but
mainly to the abdomen and breasts. Functions of
binders include the following: Double T-binder Single T-binder
♦ Provide support and relief from pain following

surgery.
♦ Hold dressings in place.
♦ Provide support for engorged breasts.
♦ Limit motion.
♦ Apply pressure to specific body parts.
Straight abdominal binder
Binders must be applied smoothly to prevent Breast binder with Velcro tabs
pressure areas, which can lead to the formation FIGURE 21-101 Different types of binders.
of pressure ulcers. Binders should fit snugly for
support but not be so tight as to cause discom-
fort. No wrinkles or creases should be present. The tail(s) is then pinned at the waist. This type of
Different types of binders are available for binder is used to hold perineal dressings in place
use (figure 21-101). The type used most frequently or provide support. In most instances, T-binders
is a straight binder. It can be applied to the abdo- have been replaced by scrotal supports for men
men, back, or rib cage. Some straight binders and self-adhesive sanitary napkins for women.
have Velcro tabs; others are pinned in place. If Binders are applied from bottom to top for
pins are used, they should be placed no more optimal support. In this way, organs can be sup-
than 2 inches apart for optimal support. If the ported correctly. Circulation and breathing
waist on a straight binder is too large, darts can should always be checked after binders are
be made to ease the excess material. Breast bind- applied. A binder that is too tight can cause severe
ers are used to support the breasts of a female complications. In addition, binders should be
patient. They can be used to support engorged removed at intervals and skin care should be pro-
breasts (breasts full of milk) after childbirth. Sin- vided to the skin under the binder.
gle T-binders are used for female patients, and
double T-binders are used for male patients. The STUDENT: Go to the workbook and complete
binder is placed around the patient’s waist, and the assignment sheet for 21:14, Applying Binders.
the tail(s) is passed between the patient’s legs. Then return and continue with the procedure.
PROCEDURE 21:14
Applying a Straight Procedure
Binder 1. Check physician’s orders or obtain
Equipment and Supplies supervisor.
Straight binder, safety pins (if needed), soap, 2. Assemble supplies.

pen or pencil NOTE: If the binder requires the use of
pins (has no Velcro tabs), insert the pins
918 CHAPTER 21
PROCEDURE 21:14
in the bar of soap. This allows for easier
insertion.
4. Wash hands.
5. Close the door and screen the unit. Ele-
vate the bed to a comfortable working
6. Fanfold the top bed linen down to the
patient’s pubic area. Arrange the bed-
clothes so that the abdomen is FIGURE 21-102A Position the binder under
exposed. the patient with the center fold at the patient’s
spine and the bottom edge at the base of the
7. Assist the patient to move to the near
spine.
side of the bed.
CAUTION: Use correct body mechanics
when applying binders.
8. With the inside facing out, fold the
binder in half to determine where the
center is.
9. Ask the patient to flex the knees, place
his or her weight on the heels, and raise
the hips.
NOTE: The patient can also turn on his
or her side, if this is easier.
10. Unfold the binder and slide it under the
patient (figure 21-102A). Keep your
thumbs at the edge of the center fold. FIGURE 21-102B Secure the Velcro tabs of
Position the binder by putting the cen- the binder by starting at the bottom edge and
ter fold at the center of the patient’s working in an upward direction.
spine. The bottom edge should be at the
base of the spine but not so low as to b. For pins, start at the lower edge.
interfere with the use of a bedpan. Overlap the edges. Place pins no
11. Open the binder completely. Check more than 2 inches apart.
placement. Make sure the binder is CAUTION: To avoid sticking the patient
smooth and even, with no wrinkles. with pins, place your hands between the
12. Fasten the binder from the bottom to binder and the patient’s skin before
the top. inserting the pins.
a. For Velcro tabs, pull the sides together 13. Check the waist of the binder. If it is too
firmly. Start at the bottom edge and large, make darts for a better fit. Insert
seal in an upward direction (figure pins vertically to hold the darts in
21-102B). place.
PROCEDURE 21:14
CAUTION: Avoid placing pins over bony straight binder applied to abdomen,
prominences. and your signature and title. Report any
14. Check the entire binder. Make sure it is
snug but not too tight. Make sure it is
smooth and positioned correctly. Check
to be sure that it is not restricting breath-
ing and/or circulation.
15. Replace all bed linens. Practice
16. Observe all checkpoints before leaving Go to the workbook and use the
the patient: position the patient in cor- evaluation sheet for 21:14, Applying
rect body alignment, elevate the side- a Straight Binder, to practice this
rails (if indicated), lower the bed to its procedure. When you believe you
lowest level, place the call signal and have mastered this skill, sign the
supplies within easy reach of the patient, sheet and give it to your instructor
and leave the area neat and clean. for further action.
17. Replace equipment.
18. Wash hands.
19. Report and/or record all required infor- Final Checkpoint Using the criteria
mation on the patient’s chart or the listed on the evaluation sheet, your
agency form, for example, date, time, instructor will grade your performance.
21:15 INFORMATION A physician’s order is usually required for

the administration of oxygen. The order will
Administering Oxygen include the method of administration and the
concentration to be given. In cases of extreme
This section provides facts about adminis- emergency, oxygen can be started with standard
tering oxygen. Check your legal responsibili- concentrations, and the physician notified as
ties with regard to this procedure. Some states soon as possible. Most rescue teams, ambulance
prohibit administration of oxygen by a health personnel, and others involved in emergency
care assistant. work follow specific orders regarding oxygen
The blood must have oxygen. The blood’s administration.
supply of oxygen is normally obtained from the
air. Air is approximately 20 percent oxygen. As a
result of accident, injury, or respiratory disease,
however, the body may be unable to take in
METHODS OF OXYGEN
enough oxygen or to use oxygen effectively. In ADMINISTRATION
such cases, oxygen can be given to the patient by
Oxygen is usually administered by one of the fol-
various means.
lowing methods:
The signs of an oxygen shortage are rapid and
shallow respirations, rapid pulse, restlessness, ♦ Mask (figure 21-103A): The mask should cover
and cyanosis. A deficiency of oxygen is called the mouth and the nose. It should fit snugly to
hypoxia. Lack of oxygen can cause brain damage prevent loss of oxygen, but it should not be so
in 4–6 minutes. tight as to cause discomfort to the patient.
920 CHAPTER 21
mouth to breathe, the concentration of oxy-

gen is reduced. The rate of flow by cannula is
usually 2–6 liters per minute.
♦ Catheter (figure 21-103C): The catheter is a
long, narrow, plastic or rubber tube that is
passed through a nostril and to the pharynx. It
is inserted by a physician, registered nurse,
respiratory therapist, or other specially trained
individual. The rate of flow is usually 2–6 liters
per minute.
♦ Tent: The tent surrounds the patient with a
high concentration of oxygen. It is often used
for small children or restless patients who are
not able to cooperate well with other meth-
FIGURE 21-103A The oxygen mask covers the ods. Oxygen and humidity are provided. A
nose and mouth and provides a high concentration common example is a croupette used with
of oxygen.
infants and small children. The flow rate is
usually 10–12 liters per minute.
Oxygen by mask is the method of administra-
tion used most frequently by rescue person-
nel. It provides the highest concentration of
oxygen. However, some patients are fright-
OXYGEN DELIVERY
ened by the mask. A careful explanation of its SYSTEMS
purpose along with constant reassurance are
necessary. The rate of flow by mask is usually Different systems can be used to provide oxygen.
6–10 liters per minute. Masks should never be Most hospitals pipe in oxygen through the wall. A
used with flow rates less than 5 liters per min- flow meter for the oxygen is plugged into an adap-
ute because the patient will rebreathe carbon tor in the wall (figure 21-104A). When the flow
dioxide and feel smothered. meter is turned on, oxygen is delivered. Oxygen is
color coded with a green label in the United
♦ Cannula (figure 21-103B): The cannula con- States. The wall adaptor usually has a green label
sists of two small, curved, plastic tubes, which
with the word oxygen or the symbol O2, Portable
are placed one in each nostril. The other end oxygen cylinders are used while transporting
of the cannula is attached to an oxygen tank or patients, in emergencies, in some long-term care
unit. The patient must be instructed to breathe facilities, and in home situations (figure 21-104B).
through the nose. If the patient opens the
FIGURE 21-103B When a nasal cannula is used FIGURE 21-103C A nasal catheter is passed
to provide oxygen, the patient must breathe through through a nostril and to the pharynx, or throat, to
the nose. administer oxygen.
Oxygen Wall
Flow meter Adaptor
Humidifier
Adapter
Humidifier
FIGURE 21-104B Portable oxygen cylinders can

be used to provide oxygen in health care facilities,
emergency care units, and homes.
FIGURE 21-104A When oxygen is piped through

a wall, the flow meter is plugged into a wall adaptor.
A humidifier is used to moisturize the oxygen.
Other health care facilities, such as some long-

term care facilities, medical offices, or dental
offices, may have piped in oxygen. However, in
most cases, they use oxygen cylinders or oxygen
concentrators. An oxygen concentrator removes
impurities and other gases from room air to con-
centrate oxygen in the unit (figure 21-104C). The
oxygen concentrator cannot be used with oxygen
masks because it provides only low liter flow
rates, usually 2–4 liters per minute. A filter on the
oxygen concentrator must be cleaned frequently
by washing it with warm soapy water, rinsing it,
and squeezing it dry before replacing it in the
unit.
Pure oxygen is very drying and can damage or
irritate mucous membranes. Therefore, oxygen
must be moisturized by passing it through water
before it is administered to the patient. A humid- FIGURE 21-104C Oxygen concentrators remove
ifier is used to moisturize oxygen (refer to figure impurities and other gases from room air to concen-
21-104A). Many health care facilities use prefilled trate oxygen in the unit.
922 CHAPTER 21
disposable humidifiers. These units are changed ♦ Cotton blankets should be used in place of
and discarded when they are empty. They must wool or nylon. In addition, all bed linen, bed-
be changed at least once each week or according spreads, and gowns or pajamas should be cot-
to the manufacturer’s instructions. Some facili- ton instead of synthetic materials. Cotton is
ties use refillable humidifiers. These humidifiers static-free, and its use decreases the danger of
must be filled with distilled water to the proper static electricity.
level, usually one-half to two-thirds of the con-
tainer. Most humidifiers are marked for the
♦ Frequent inspections must be made of any
area where oxygen is in use. Sources of sparks
proper level. Distilled water is usually used to
or static electricity should be removed.
prevent mineral deposits on the equipment.
Refillable humidifiers must be washed and steril-
ized every 24 hours to prevent infection. A label is
usually placed on the humidifier to indicate the
PULSE OXIMETERS
date and time it was changed. Additional water Pulse oximeters may be used to monitor the
should never be added to a partially filled humid- patient who is receiving oxygen (figure 21-105).
ifier. In emergency situations when oxygen is An oximeter measures the level of oxygen in arte-
given for short periods of time during transporta- rial blood. A photo-detector probe is clipped on
tion to a medical facility, the oxygen may not be the patient’s finger or earlobe. The percentage of
humidified. oxygen in the arterial blood is displayed on the
monitor screen of the oximeter. If the oxygen level
falls below the minimum percentage pro-
SAFETY PRECAUTIONS grammed into the oximeter, an alarm will sound.
Licensed personnel are responsible for program-
Safety precautions must be observed when ming and monitoring the oximeter. The health
oxygen is in use. Although oxygen does not care assistant should make sure the probe is not
explode, burning is more rapid and intense in the disturbed and notify a supervisor if the alarm
presence of oxygen. Flammable materials (those sounds.
that burn) will burn much more rapidly in the
presence of oxygen. The following precautions
should be taken whenever oxygen is in use:
♦ Smoking, lighting cigarettes or matches, burn-
ing candles, and the use of open flames are
prohibited when oxygen is in use. In patient-
care areas, a warning sign reading, for exam-
ple, “No Smoking—Oxygen” is placed on the
door to the patient’s room, on the bed, or on
the wall nearby. Warning labels are also some-
times placed on tanks used by emergency
rescue personnel.
♦ The sign is not enough. The patient must be
cautioned against smoking. Observers at the
scene of an accident or emergency situation,
and visitors in a patient-care area must also be
told to avoid smoking.
♦ The use of electrically operated equipment,
which could cause sparks, should be avoided.
♦ Flammable liquids such as nail polish remover
or adhesive tape remover should never be FIGURE 21-105 Pulse oximeters may be used to
used while oxygen is in use. Alcohol-based monitor the patient who is receiving oxygen. The
aftershave lotions, hairspray, and perfumes oximeter measures the level of oxygen in arterial
should not be used for patient care. blood.
ties, oxygen administration is the responsibility

SUMMARY of the respiratory therapy department. However,
the health care worker, who is with the patient
A patient who is receiving oxygen must be
more frequently, should always be aware of safety
checked frequently. Quality of respirations
precautions and check patients carefully. Any
should be noted. Mouth and nose care must be
abnormal observations should be reported
provided if a mask, catheter, or cannula is used.
immediately.
The rate of flow of oxygen should be checked.
Watch to make sure that the patient and/or visi-
tors do not change the liter flow. If a humidifier is STUDENT: Go to the workbook and complete
used, the water level must be checked and the the assignment sheet for 21:15, Administering
humidifier replaced as indicated. Safety precau- Oxygen. Then return and continue with the proce-
tions must be checked frequently. In many facili- dure.
PROCEDURE 21:15
humidifier is used, follow manufactur-
Administering Oxygen er’s instructions to release the seal and
attach it to the flow meter. If a refillable
Equipment and Supplies humidifier is used, fill the container
with distilled water. Distilled water pre-
Oxygen mask, cannula, or tent; tubing and vents mineral deposits from forming.
gauge; oxygen tank or supply; distilled water Replace the lid and connect it to the flow
(if refillable humidifier is used); pen or pencil meter or oxygen outlet.
CAUTION: Some states prohibit the 6. Turn on the oxygen supply.
administration of oxygen by a health
care assistant. Check your legal respon- CAUTION: Do not insert the nasal can-
sibilities in regard to this procedure. nula or apply the mask at this time. Reg-
ulate the gauge to the correct liter flow
Procedure rate per minute (figure 21-106).
CAUTION: Make sure to follow specific
1. Read the physician’s orders or obtain manufacturer’s instructions or agency
orders from your immediate supervisor. policy for connecting and turning on
In emergency rescue situations, stan- the oxygen supply. Do not operate any
dard orders are usually provided for vic- oxygen equipment until you have been
tims requiring oxygen. The orders specifically instructed on how to use it.
should state the method of administra-
tion and liter flow per minute. 7. Check to be sure that oxygen is passing
through the tubing. Place your hand by
2. Assemble equipment. the outlet on the mask or cannula.
3. Knock on the door and pause before 8. Put on disposable gloves.
the patient. Explain the procedure to CAUTION: Observe all standard precau-
the patient. Patients are often appre- tions if contact with the patient’s oral or
hensive. Reassure as needed. nasal secretions is possible.
4. Wash hands. In emergency situations, 9. With the oxygen still flowing, apply the
this may not be possible. mask or cannula to the patient. If a mask
is used, position it over the patient’s
5. Connect the tubing from the oxygen nose and mouth. Adjust the strap so that
supply (tank or wall unit) to the tubing it fits snugly but does not apply pressure
on the mask or cannula. If a prefilled
924 CHAPTER 21
PROCEDURE 21:15
and provide skin care if a nasal cannula
is used. At times, it may be necessary to
use a towel or cloth to dry the inside of
the mask, because moisture will accu-
mulate in the mask. If a nasal cannula is
used, check the tips to make sure they
are open and not plugged by mucus.
Provide oral hygiene frequently. Check
the water level, if a humidifier is used
and replace the humidifier as needed.
Check the gauge and make sure the liter
flow rate is correct. Report any abnor-
mal conditions immediately.
13. When the oxygen is discontinued, make
sure that the oxygen supply is turned
FIGURE 21-106 Regulate the gauge to off. Follow specific manufacturer’s
provide the correct liter flow rate for oxygen. instructions or agency policy. Clean and
replace all equipment. Most masks and
to the face. If a cannula is used, place cannulas are disposable and are dis-
the two tips in the patient’s nostrils and carded after use. If the items are not dis-
loop the tubing around each ear. Adjust posable, they should be cleaned and
the straps at the neck so that the tips disinfected according to established
remain in position. Instruct the patient agency policy.
to breathe through the nose.
14. Wash hands.
10. If a tent is used, it is first filled with oxy-
gen; then, the prescribed liter flow is set. 15. Report and/or record all required infor-
The humidifier is filled to the marked mation on the patient’s chart or the
level with distilled water. The tent is agency form; for example, date; time;
placed over the bed or crib, and the oxygen per mask at 6 L/min, R 16 deep
edges are tucked in on all sides to pre- and even; and your signature and title.
vent oxygen loss. A cotton blanket, bath Report any unusual observations imme-
blanket, or sheet can be used to provide diately.
a cuff around the loose end covering the
patient.
11. Check the surrounding area to make
sure all safety precautions are being Practice
observed. Eliminate any sources of Go to the workbook and use the
sparks or flames. Caution any visitors evaluation sheet for 21:15,
and the patient against smoking while Administering Oxygen, to practice
the oxygen is in use. In a patient-care this procedure. When you believe
area, make sure a sign is posted on the you have mastered this skill, sign
door or in the immediate area. the sheet and give it to your
12. Check the patient at frequent intervals.
Note respirations, color, restlessness, or
discomfort. Provide skin care to the face Final Checkpoint Using the criteria
and/or nose, if a mask or cannula is listed on the evaluation sheet, your
used. Check the skin behind the ears instructor will grade your performance.
Morgue kits often are used for postmortem

21:16 INFORMATION care (figure 21-107). Each kit usually contains a
shroud or body bag, a gown, chin strap, pads,
Giving Postmortem Care gauze squares, ties, two or three tags to identify
Providing care after death is a difficult but the body, and safety pins. Procedure 21:16
essential part of patient care. As a health care describes one method of using these supplies to
worker, you may perform or assist with this care. provide postmortem care.
Postmortem care is care given to the body Care of the patient’s valuables and belongings
immediately after death. It begins when a physi- is an important part of postmortem care. Each
cian has pronounced the patient dead. facility has a policy that should be followed. The
Dealing with death and dying is a difficult personal inventory and valuables lists prepared
part of providing care. If a health care worker has on admission are often used to make sure that all
cared for a patient over a period of time, it is nat- items are present. These items are checked
ural for the worker to feel grief and a sense of loss according to facility policy. Valuables in the safe
upon the patient’s death. Crying is a natural usually remain there until a family member signs
expression of grief, and you should not feel for them. Jewelry is usually removed from the
embarrassed if you cry. However, it is also impor- body, listed, and placed in the safe until received
tant for health care workers to try to control emo- by a family member. A wedding ring is frequently
tions because family members and other patients left on the body, but it should be taped in place
will need their support. and noted on the chart.
The patient’s rights continue to apply after Frequently, two people work together to
death. The body should be treated with dig- complete postmortem care. Some aspects
nity and respect. Privacy should be provided at all of care, such as removal of tubes or IVs, may be
times. the responsibility of the nurse or another autho-
If family members are not present when death rized person. Follow your agency’s policy and
occurs and want to view the body before it is know your legal responsibilities with regard to
taken to the morgue or funeral home, the body giving or assisting with postmortem care.
should be prepared for viewing. The patient
should be positioned naturally, with the limbs
the assignment sheet for 21:16, Giving Postmor-
straight. Elevate the head of the bed 30 degrees to
tem Care. Then return and continue with the pro-
prevent discoloration of the head and neck. Fol-
cedure.
low agency policy regarding dentures and glasses. The Morgue Kit
Some facilities state dentures and glasses should
be placed on the patient for family viewing. After
the viewing, they are removed, packed safely, and
sent to the funeral home with the body. Other
facilities state that the dentures and glasses must
be packed immediately and not placed on the Plastic bag
Tags (for personal belongings) Ties
body because the items could fall off and break.
The bed linen should be neat and clean, and extra
equipment should be removed from the unit.
Provide privacy while the family views the body,
unless they request that you remain with them.
After the family has viewed the body, post-
mortem care is completed. The procedure for this Cellu-cotton pads
care varies in different facilities. In some facili-
ties, morgue personnel prepare the body and Plastic shroud
remove it to the morgue. In other facilities, the (body bag)
Chin strap
body is prepared and remains in the unit until the
funeral home personnel arrive. In yet other facili-
ties, funeral home personnel remove the body
and provide postmortem care. Know and follow FIGURE 21-107 Supplies needed for postmor-
the procedure established by your facility. tem care.
926 CHAPTER 21
PROCEDURE 21:16
Giving Postmortem
Care
Postmortem kit (shroud or clean sheet, gown,
tags, gauze squares, cotton balls, safety pins),
underpads or bed protectors, basin, towels,
washcloth, personal inventory and valuables
lists, disposable gloves, plastic waste bag, pen
or pencil
FIGURE 21-108 If the eyes are open after
Procedure death, close them by gently pulling the eyelids
over the eyes.
ble equipment.
cies state that dentures should be
2. Identify the patient by checking the replaced in the mouth for family view-
armband. ing. Others state that they should be
3. Close the door and screen the unit to packed securely in a denture cup
provide privacy. because they could fall out of the mouth
and break. Some agencies use a chin
4. Wash hands. Put on gloves. strap to hold the jaw shut. Other agen-
CAUTION: If the body is contaminated cies feel that the chin strap can bruise or
with blood or body fluids, observe stan- discolor the skin and that it should not
dard precautions. be used. Some agencies use a rolled
towel or padding under the chin to keep
the mouth closed.
where you are working. 9. Remove soiled dressings and replace
with clean ones, as necessary. If tubes,
6. Position the body lying flat on the back,
IVs, catheters, or drainage bags are in
with the arms and legs straight. Place a
place, follow agency policy for removal.
pillow under the head and shoulders
This is often the responsibility of the
and elevate the bed 30 degrees.
nurse. If an autopsy is to be performed,
NOTE: The head is elevated to prevent some tubes may have to be left in place.
the bluish purple discoloration of the
10. Use warm water to bathe any soiled
head and neck that occurs in dependent
body areas. Dry all areas thoroughly.
areas of the body after death.
Comb the hair, if needed.
NOTE: Handle the body gently and with
11. Place an underpad or padding under
respect.
the buttocks at the anal area.
7. If the eyes are open, close them by gen-
NOTE: The bowels and bladder may
tly pulling the eyelids over the eyes (fig-
empty after death.
ure 21-108). Put a moist cotton ball on
each eye if the eyes do not remain shut. 12. If gloves are worn, remove gloves and
wash hands.
8. Follow agency policy regarding the use
of dentures and chin straps. Some agen- 13. Put a clean gown on the body.
PROCEDURE 21:16
14. If jewelry is present, follow agency pol- for care of belongings until they are
icy. Jewelry is usually removed, listed on signed for by a family member.
a valuables list, and stored in a safe until
21. Obtain assistance and transfer the body
signed for by a family member. A wed-
to a stretcher. Make sure doors to other
ding ring frequently is left on the body,
patient’s rooms are closed and the cor-
but it should be taped in place and noted
ridor is empty before transporting the
on the chart or postmortem form.
body to the morgue.
15. If the family is to view the body, use a
NOTE: In some facilities, morgue per-
sheet to cover the body to the shoulders.
sonnel transport the body to the morgue.
Make sure the room is neat and clean.
In other facilities, the body remains in
Provide privacy for the family unless
the unit until funeral home personnel
they request that you remain with
arrive.
them.
22. Return to the unit. Strip the linen from
16. After the family visit, remove dentures
the bed. Follow agency policy for clean-
and eyeglasses (if they were placed on
ing the unit and equipment. Leave the
the patient). Pack them securely, label
them with the patient’s name, and send
them to the funeral home. 23. Wash hands.
17. Fill out the identification card or tag. 24. Report and/or record all required infor-
One tag is usually placed on the patient’s mation on the patient’s chart or the
right ankle or right big toe. agency form, for example, date; time;
postmortem care given, body trans-
18. Place the body in the shroud or body
ported to morgue, belongings placed in
bag. Use safety pins or tape to hold the
locked closet by nurses’ station; and
shroud in place. If a shroud is not avail-
your signature and title.
able, use a sheet to cover the body.
CAUTION: Handle the body carefully.
Pressure from your hands can leave
marks on the body.
NOTE: Sometimes, padding is placed
between the ankles and knees, and the
Practice
legs are tied together lightly before the
body is placed in the shroud. evaluation sheet for 21:16, Giving
Postmortem Care, to practice this
19. If required, attach a second identifica- procedure. When you believe you
tion card or tag to the outside of the have mastered this skill, sign the
shroud. sheet and give it to your instructor
20. Collect all belongings and make a list. for further action.
This list frequently is checked against
the admission personal inventory and/
or valuables list to make sure that all
items are present. Put the items in a bag Final Checkpoint Using the criteria
or container and attach an identifica- listed on the evaluation sheet, your
tion card or tag. Follow agency policy instructor will grade your performance.
928 CHAPTER 21

Gene therapy that cures cancer?
Liver cancer kills. The American Cancer Society estimates that more than 17,500 new
cases of liver cancer are diagnosed each year. About 15,400 people die of liver cancer every
year. How can these lives be saved?
Researchers are experimenting with many different treatments for liver cancer. One
treatment involves the use of gene therapy. Every human has between 50,000 and 100,000
different genes. These genes determine what a person inherits, such as hair and eye color.
Genes also carry instructions that tell cells to perform certain functions, such as telling cells
when to reproduce and grow. Scientists researching the spread of liver cancer to the colon
and rectum have identified a gene called p53. This gene is present in normal cells and regu-
lates cell growth. In many types of cancer it is missing or changed, allowing uncontrolled
growth of the cancer cells. Scientists hope that by replacing this missing gene, they will be
able to stop or decrease the growth of cancer so other treatments will be more effective.
One major problem of gene therapy is the way the gene has to be inserted into a person’s
cell. Scientists cannot simply inject genes into cells. They must be transported into the cell
by using a carrier called a vector. The most common vectors used are retroviruses. Scientists
inactivate the retroviruses to keep them from causing disease and then use them to carry the
gene into cells. The problems that occur with this method are that the genes might alter or
change other normal cells, or that the new gene might be inserted in the wrong location,
causing additional damage to the body. For these reasons, scientists must identify easier
and better ways to deliver genes to body cells. Scientists throughout the world are trying to
solve these problems. If they are successful, many people with cancer will be cured.
CHAPTER 21 SUMMARY collecting stool and urine specimens, giving en-

emas, assisting the surgical patient, administer-
ing oxygen, applying restraints, providing cath-
Many nurse assistant skills are directed toward eter care, applying binders or surgical hose, and
providing quality personal care for the patient. giving postmortem care. It is important to de-
Examples include bathing, caring for hair and termine legal responsibility before performing
nails, gowning or dressing the patient, giving some of the special procedures, because some
backrubs, providing oral hygiene, shaving, feed- states or agencies do not allow all nurse assis-
ing, assisting with bedpans or urinals, and bed- tants to perform the procedures.
making. It is essential that the nurse assistant While performing any nurse assistant skill,
learn and follow correct procedures to provide it is essential to use approved procedures
for the safety, comfort, and privacy of the pa- and make every effort to provide quality care to
tient. the patient. In addition, if any contact with blood,
Other nurse assistant skills include position- body fluids, secretions, or excretions is possible,
ing, turning, moving, and transferring patients. standard precautions must be observed. Finally,
During any move or transfer, the use of correct it is important to make careful observations of
body mechanics is essential. the patient while providing care, and to record
Nurse assistant skills are also used in other or report these observations correctly. In this
special procedures. Examples of these pro- way, you will use nurse assistant skills to become
cedures include measuring intake and output, an important member of the health care team.
INTERNET SEARCHES 9. Define each of the following words:

a. ostomy
Use the suggested search engines in Chapter 12:4 b. suppository
of this textbook to search the Internet for addi- c. fecal impaction
tional information on the following topics: d. enema
e. flatus
1. Organizations: research nurse assisting careers,
educational requirements, and duties at 10. Differentiate between a retention and a
organizational sites such as the American nonretention enema. Give an example for each
Health Care Association, American Hospital type.
Association, American Nurse’s Association, 11. List four (4) specific rules that OBRA legislation
Association of Surgical Technologists, Founda- has placed on the use of restraints.
tion for Hospice and Homecare, National
Association for Practical Nurse Education and 12. Identify five (5) specific aspects of care for both
Service, National League for Nursing, and the pre-op and post-op patients.
National Federation of Licensed Practical 13. Name the three (3) main methods for adminis-
Nurses tering oxygen. List the average flow rate for
2. Patient care: research patient’s rights, hospice each method.
care, home health care, oncology care, surgical 14. Explain five (5) standard precautions that must
care, and postmortem care be observed while performing any nurse
3. Suppliers: find suppliers of hospital and assisting procedure.
medical equipment to compare the different
products available For additional information on nursing
careers, contact the following associations:
REVIEW QUESTIONS ♦ American Health Care Association

1201 L Street NW
1. List six (6) specific tasks that must be per- Internet address: www.ahca.org
formed while admitting a patient to a hospital
or long-term care facility.
♦ American Nurses’ Association
8515 Georgia Avenue, Suite 400
2. Describe four (4) ways to prevent pressure Silver Springs, MD 20910
sores and/or contractors from developing. Internet address: www.nursingworld.org
3. Name three (3) main ways to make beds and ♦ National Association for Practical Nurse
explain when each type is made. Education and Service
4. Identify all the areas of care that may be P. O. Box 25647
included to provide personal hygiene to a Alexandria, VA 22313
patient. Internet address: www.napnes.org
♦ National Federation of Licensed Practical
5. Why is it important to constantly observe a
Nursing
patient while providing personal care? Identify
605 Poole Drive
six (6) observations that might be indicative of
Garner, NC 27529
a medical problem.
Internet address: www.nflpn.org
6. What is a urinary catheter? Why is it used? ♦ National League for Nursing
7. Differentiate between a routine, midstream 61 Broadway
(clean-catch), sterile, and 24-hour urine New York, NY 10006
specimen. Internet address: www.nln.org
8. Why is stool tested for occult blood? ♦ State nurses’ associations
CHAPTER 22 Physical Therapy
Skills
Chapter Objectives
Observe Standard
Precautions
◆ Perform range-of-motion (ROM) exercises on
all body joints, observing all safety precautions
◆ Ambulate a patient using a transfer (gait) belt
Instructor at This Point ◆ Check the correct measurements of patients
for canes, crutches, and walkers
Safety—Proceed with ◆ Ambulate a patient using the following crutch
Caution gaits: four point, three point, two point, swing
to, and swing through
OBRA Requirement—Based ◆ Ambulate a patient using a cane
on Federal Law
◆ Ambulate a patient using a walker
◆ Apply an ice bag or ice collar, observing all
Math Skill
safety precautions
◆ Apply a warm-water bag, observing all safety
Legal Responsibility precautions
◆ Apply an aquamatic pad, observing all safety
Science Skill precautions
◆ Apply a moist compress, observing all safety
Career Information precautions
◆ Administer a sitz bath
Communications Skill ◆ Define, pronounce, and spell all key terms
Technology
Physical Therapy Skills 931
KEY TERMS
aquathermia pads hydrocollator packs thermal blankets
(ak⬙-wah-thur⬘-me-ah) hypothermia blanket thermotherapy
cane (high⬙-poh-thur⬘-me-ah) transfer (gait) belt
compresses (cahm⬘-press-ez) ice bags vasoconstriction (vay⬙-zow⬙-
contracture ice collars kon-strik⬘-shun)
(kun-track⬘-shure) moist cold vasodilation
crutches moist heat (vay⬙-zow⬙-di-lay⬘-shun)
cryotherapy paraffin wax treatment walker
dry cold range of motion (ROM) warm-water bags
dry heat sitz bath
CAREER HIGHLIGHTS
Physical therapist assistants provide treatment to improve mobility and prevent or limit
permanent disability of patients with disabling injuries or disease. They are important mem-
bers of the health care team. They work under the supervision of a physical therapist who
has a master’s degree from an accredited program and is licensed (required in all states).
Most physical therapist assistants have an associate’s degree from an accredited program
and an internship. Licensure is required in most states.
The duties of physical therapist assistants vary but usually include performing exercises;
providing ultrasound or electrical stimulation treatments; administering heat, cold, or moist
applications; ambulating patients with assistive devices; and informing the physical therapist
of patient’s response and progress. In addition to the knowledge and skills presented in this
chapter, physical therapist assistants must also learn and master skills such as:
◆ Presenting a professional ◆ Comprehending anatomy, ◆ Promoting good nutrition
appearance and attitude physiology, and and a healthy lifestyle to
◆ Obtaining knowledge
pathophysiology with an maintain health
regarding health care emphasis on the skeletal, ◆ Utilizing computer skills
delivery systems, muscular, nervous, and
circulatory systems ◆ Cleaning and maintaining
organizational structure, equipment
and teamwork ◆ Observing all safety
precautions ◆ Ordering and maintaining
supplies and materials
responsibilities ◆ Practicing all principles of
infection control ◆ Performing administrative
◆ Communicating
effectively ◆ Administering first aid
the telephone, scheduling
◆ Being sensitive to and
and cardiopulmonary appointments,
respecting cultural resuscitation completing insurance
diversity forms, and maintaining
◆ Learning medical
patient records
terminology
932 CHAPTER 22
contracture, but contractures can also affect

22:1 INFORMATION the knees, hips, elbows, and hands.
Performing Range-of-Motion ♦ Muscle and joint function: Muscles atrophy
(shrink) and become weak. Joints become stiff
(ROM) Exercises and difficult to move.
Activity and exercise are important for all ♦ Circulatory impairment: The circulation of
individuals. When patients have limited blood is affected, and blood clots and pressure
ability to move, range-of-motion exercises help ulcers (pressure sores) can develop.
keep muscles and joints functioning.
Range-of-motion (ROM) exercises are ♦ Mineral loss: Inactivity causes mineral loss,
done to maintain the health of the musculoskel- especially of calcium from the bones. The
etal system. Each joint and muscle in the body is bones become brittle, and fractures occur. As
moved through its full range of motion. Range- the blood calcium level increases, renal calculi
of-motion exercises are frequently ordered by (kidney stones) are more likely to form.
physicians for patients with limited ability to ♦ Other problems: Lack of exercise can also
move. These exercises are administered by a cause poor appetite, constipation, urinary
physical therapist, nurse, health care assistant, or infections, respiratory problems, and hypo-
other authorized person. Range-of-motion exer- static pneumonia.
cises can be done during the daily bath or at other
There are four main types of ROM exercises:
times during the day.
Range-of-motion exercises are done to pre- ♦ Active ROM exercises: performed by patients
vent the problems caused by lack of movement who are able to move each joint without assis-
and by inactivity (figure 22-1). Some of these tance (figure 22-2). This type of ROM exercise
problems include: strengthens muscles, maintains joint function
and movement, and helps prevent deformities.
♦ Contracture: Contracture is a tightening and
shortening of a muscle, resulting in a perma- ♦ Active assistive ROM exercises: The patient
nent flexing of a joint. Foot drop is a common actively moves the joints but receives assis-
FIGURE 22-1 Range-of-motion (ROM) exercises FIGURE 22-2 Patients who are able to move each
are done to prevent problems caused by lack of joint without assistance perform active range of
movement and by inactivity. motion (ROM) exercises.
tance to complete the entire ROM. This type of Spine

ROM strengthens muscles, maintains joint
function and movement, and helps prevent
deformities. At times, equipment, such as a Cervical
Flexion, extension,
pulley, is used to complete the ROM. Lateral flexion Rotation hyperextension
♦ Passive ROM exercises: Another person moves
each joint for a patient who is not able to exer-
cise. This type of ROM maintains joint func-
tion and movement, and helps to prevent
deformities. However, it does not strengthen
muscles. Trunk
Flexion, extension,
♦ Resistive ROM exercises: Administered by a Lateral flexion Rotation hyperextension
therapist, these exercises are performed Shoulder

against resistance provided by the therapist. Abduction
This type of ROM helps the patient develop
increased strength and endurance.
The health care worker should find out what Rotation:
Adduction Flexion, extension,
type of ROM exercises are to be performed outward,
inward hyperextension
and determine whether any limitations to the
exercises exist before administering or assisting Hip
the patient with the exercises. In some states and Abduction Rotation:
outward,
health care facilities, only physical therapists or inward
registered nurses may perform ROM exercises to
the head and neck, especially if stretching is Flexion, extension,
Adduction hyperextension
involved. After hip or knee replacement surger-
ies, some ROM exercises may be restricted or lim- Elbow Flexion
ited. Patients with osteoporosis, a condition in
which the bones become porous and are prone to Pronation
fracture, may have limitations on ROMs. It is your

responsibility to check legal requirements regard- Supination Extension
ing ROM exercises. Knee
Various movements are used when per- Extension
forming ROM exercises. The health care
worker must be aware of the terms used for move-
Flexion
ments of each joint. The main movements are
shown in figure 22-3 and include: Wrist Flexion Ankle Dorsiflexion
♦ Abduction: moving a part away from the mid- Extension
line of the body

♦ Adduction: moving a part toward the midline Ulnar Radial Hyperextension Plantarflexion
flexion flexion
of the body (adduction)(abduction) Eversion Inversion
♦ Flexion: bending a body part Fingers Toes Adduction Extension
♦ Extension: straightening a body part Adduction
♦ Hyperextension: excessive straightening of a

body part
Flexion
♦ Rotation: moving a body part around its own Abduction Extension Abduction Flexion
axis, for example, turning the head from side FIGURE 22-3 Range-of-motion (ROM) exercises
to side for specific joints.
♦ Circumduction: moving in a circle at a joint, or

moving one end of a body part in a circle while
934 CHAPTER 22
the other end remains stationary, such as ♦ A joint should never be forced beyond its ROM
swinging the arm in a circle; involves all the or exercised to the point of pain, resistance, or
movements of flexion, extension, abduction, extreme fatigue.
adduction, and rotation
♦ If a patient complains of pain, stop the exer-
♦ Pronation: turning a body part downward cise and report this fact to your immediate
(turning palm down) supervisor.
♦ Supination: turning a body part upward (turn- ♦ Watch the patient closely. If you notice the
ing palm up) patient is in pain, has shortness of breath, is
♦ Opposition: touching each of the fingers with perspiring profusely (diaphoresis), or is pale,
the tip of the thumb stop the exercise and notify your supervisor.
♦ Inversion: turning a body part inward ♦ Each movement should be performed three to
♦ Eversion: turning a body part outward five times or as ordered.
♦ Dorsiflexion: bending backward (bending the ♦ The patient should be encouraged to assist as
foot toward the knee) much as possible.
♦ Plantar flexion: bending forward (straighten- ♦ Prevent unnecessary exposure of the patient.
ing the foot away from the knee) Only the body part being exercised should be
♦ Radial deviation: moving toward the thumb exposed.
side of the hand ♦ The door should be closed and the unit
♦ Ulnar deviation: moving toward the little fin- screened to provide privacy.
ger side of the hand ♦ Use correct body mechanics at all times to
Certain principles must be observed at all prevent injury.
times when performing ROM exercises:
♦ Movements should be slow, smooth, and gen- STUDENT: Go to the workbook and complete
tle to prevent injury. the assignment sheet for 22:1, Performing Range-
♦ Support should be provided to the parts above of-Motion (ROM) Exercises. Then return and con-
and below the joint being exercised. tinue with the procedure.
PROCEDURE 22:1
2. Assemble supplies.
Performing Range-of-
Motion (ROM) entering. Introduce yourself. Identify
Exercises the patient. Explain the procedure.
4. Close the door and screen the unit. Lock
Equipment and Supplies the wheels of the bed to prevent move-
ment.
Bath blanket, pen or pencil
5. Wash hands.
Procedure 6. Elevate the bed to a comfortable work-
1. Obtain proper authorization. Deter- where you are working.
mine the type of ROM exercises and any
limitations to movement. 7. Position the patient in the supine posi-
tion (on the back) and in good body
CAUTION: Remember it is your respon- alignment.
sibility to check legal requirements
regarding ROMs.
PROCEDURE 22:1
NOTE: Some ROM exercises can be done
while patient is sitting in a chair.
8. Use the bath blanket to drape the
patient. Fanfold the top bed linens to
the foot of the bed.
9. Administer the exercises in an organized
manner. Start at the head and move to
the feet. Complete one side of the body
first and then work on the opposite side
of the body. Perform each movement
three to five times or as ordered. Provide
support for the body parts above and
below the joint being exercised. Never FIGURE 22-4 Flex the neck by moving the
force any joint beyond its ROM or cause chin toward the chest.
pain while exercising a joint. d. Extend the neck by returning the
CAUTION: Use proper body mechanics head to the upright position.
when administering ROM exercises. Get e. Hyperextend the neck by tilting the
close to the patient by bending at your head backward.
hips and knees and keeping your back
straight. Stand with your feet apart and f. Laterally flex or rotate the neck by
one foot slightly forward to provide a moving the head first toward the right
good base of support. shoulder and then toward the left
shoulder.
CAUTION: If the patient complains of
pain or discomfort, begins to perspire 11. Exercise the shoulder joint nearest you:
profusely, or has difficulty breathing a. Support the patient’s arm by placing
during any exercise, stop the exercise one hand at the elbow and the other
and report the fact to your immediate at the wrist.
supervisor.
b. Abduct the shoulder by bringing the
10. Exercise the neck, if you have specific arm straight out at a right angle to
orders to do so: the body (figure 22-5A).
CAUTION: In some states and health
care facilities, only physical therapists
or registered nurses may perform ROMs
to the head and neck. Check your legal
responsibilities.
a. Support the patient’s head by placing
one hand under the chin and the
other hand on the top-back part of
the head.
NOTE: Hands can also be placed on
either side of the patient’s head.
b. Rotate the neck by turning the head
gently from side to side.
FIGURE 22-5A Abduct the shoulder by
c. Flex the neck by moving the chin bringing the arm straight out at a right angle to
toward the chest (figure 22-4). the body.
936 CHAPTER 22
PROCEDURE 22:1
c. Adduct the shoulder by moving the b. Flex the elbow by bending the fore-
arm straight in to the side (figure arm and hand up to the shoulder
22-5B). (figure 22-7A).
d. Flex the shoulder by raising the arm c. Extend the elbow by moving the fore-
in front of the body and then above arm and hand down to the side, or
the head (figure 22-6). straightening the arm (figure 22-7B).
e. Extend the shoulder by bringing the d. Pronate by turning the forearm and
arm back down to the side from above hand so that the palm of the hand is
the head. down.
12. Exercise the elbow joint nearest you: e. Supinate by turning the forearm and
hand so that the palm of the hand is
a. Support the patient’s arm by placing
up.
one hand on the elbow and the other
hand on the wrist.
FIGURE 22-5B Adduct the shoulder by

moving the arm straight in to the body.
FIGURE 22-7A Flex the elbow by bending the
forearm and hand up to the shoulder.
FIGURE 22-6 Flex the shoulder by raising the

arm in front of the body and then above the FIGURE 22-7B Extend the elbow by moving
head. the forearm and hand down to the side.
PROCEDURE 22:1
13. Exercise the wrist nearest you:
a. Support the patient’s wrist by placing
one hand above it and the other hand
below it.
b. Flex the wrist by bending the hand
down toward the forearm (figure
22-8A).
c. Extend the wrist by straightening the
hand (figure 22-8B).
d. Hyperextend the wrist by bending
the top of the hand back toward the FIGURE 22-9 Deviate the wrist in an ulnar
forearm. direction by moving the hand toward the little
finger side and in a radial direction by moving it
e. Deviate the wrist in an ulnar direc- toward the thumb side.
tion by moving the hand toward the
little finger side (figure 22-9). f. Deviate the wrist in a radial direction
by moving the hand toward the
thumb side.
14. Exercise the fingers and thumb on the
hand nearest you:
a. Support the patient’s hand by placing
one hand at the wrist.
b. Flex the thumb and fingers by bend-
ing them toward the palm (figure
22-10A).
c. Extend the thumb and fingers by
straightening them (figure 22-10B).
d. Abduct the thumb and fingers by
FIGURE 22-8A Flex the wrist by bending the spreading them apart (figure 22-11A).
hand down toward the forearm.
e. Adduct the thumb and fingers by mov-
ing them together (figure 22-11B).
FIGURE 22-8B Extend the wrist by straight- FIGURE 22-10A Flex the thumb and fingers
ening the hand. by bending them toward the palm.
938 CHAPTER 22
PROCEDURE 22:1
a. Support the patient’s leg by placing
one hand under the knee and the
other hand under the ankle.
b. Abduct the hip by moving the entire
leg out to the side (figure 22-12A).
c. Adduct the hip by moving the entire
leg back toward the body (figure
22-12B).
d. Flex the hip by bending the knee and
moving the thigh up toward the
FIGURE 22-10B Extend the thumb and abdomen (figure 22-13A).
fingers by straightening them. e. Extend the hip by straightening the
knee and moving the leg away from
f. Perform opposition by touching the
the abdomen (figure 22-13B).
thumb to the tip of each finger (fig-
ure 22-11C). f. Medially rotate the hip by bending
the knee and turning the leg in toward
g. Circumduct the thumb by moving it
the midline.
in a circular motion.
15. Uncover the leg nearest you and exer-
cise the hip:
CAUTION: If the patient had hip or knee
replacement surgery, check first for any
limitations or restrictions to ROMs.
FIGURE 22-12A Abduct the hip by moving

the entire leg out to the side.
A B
C
FIGURE 22-11 (A) Abduct the thumb and
fingers by spreading them apart. (B) Adduct the
thumb and fingers by moving them together. (C)
Perform opposition by touching the thumb to the FIGURE 22-12B Adduct the hip by moving
tip of each finger. the entire leg back toward the body.
PROCEDURE 22:1
b. Dorsiflex the ankle by moving the
toes and foot up toward the knee (fig-
ure 22-14A).
c. Plantar flex the ankle by moving the
toes and foot down away from the
knee (figure 22-14B).
d. Invert the foot by gently turning it
inward.
FIGURE 22-13A Flex the hip by bending the e. Evert the foot by gently turning it
knee and moving the thigh up toward the outward.
abdomen.
18. Exercise the toes on the foot nearest
you:
a. Rest the patient’s leg and foot on the
bed for support.
b. Abduct the toes by separating them,
or moving them away from each
other.
c. Adduct the toes by moving them
together.
FIGURE 22-13B Extend the hip by straight- d. Flex the toes by bending them down
ening the knee and moving the leg away from toward the bottom of the foot.
the abdomen.
g. Laterally rotate the hip by bending

the knee and turning the leg out away
from the midline.
16. Exercise the knee nearest you:
CAUTION: If the patient had hip or knee
replacement surgery, check first for any
limitations or restrictions to ROM exer-
cises.
FIGURE 22-14A Dorsiflex the ankle by
moving the toes and foot up toward the knee.
a. Support the patient’s leg by placing
one hand under the knee and the
other hand under the ankle.
b. Flex the knee by bending the lower
leg back toward the thigh.
c. Extend the knee by straightening the
leg.
17. Exercise the ankle nearest you:
a. Support the patient’s foot by placing FIGURE 22-14B Plantar flex the ankle by
one hand under the foot and the moving the toes and foot down away from the
other hand behind the ankle. knee.
940 CHAPTER 22
PROCEDURE 22:1
e. Extend the toes by straightening agency form; for example, date; time;
them. ROM exercises performed on all joints,
patient assisted with movements of
19. Use the bath blanket to cover the patient.
arms and hands; and your signature and
Raise the siderail and move to the oppo-
site side of the bed. Lower the siderail.
immediately.
20. Repeat steps 11–18.
21. When ROM exercises are complete,
comfortably position the patient in good
body alignment. Replace the top bed Practice
linens and remove the bath blanket. Go to the workbook and use the
evaluation sheet for 22:1, Performing
Range-of-Motion (ROM) Exercises, to
area neat and clean. instructor for further action.
23. Wash hands.

24. Report and/or record all required infor- listed on the evaluation sheet, your
mation on the patient’s chart or the instructor will grade your performance.
22:2 INFORMATION
Ambulating Patients Who Use
Transfer (Gait) Belts, Crutches,
Canes, or Walkers
Many patients require aids, or assistive
devices, when ambulating. The type used
depends on the injury and the patient’s condi-
tion. However, certain points must be observed
when a patient uses crutches, canes, or a walker.
TRANSFER (GAIT) BELT

A transfer (gait) belt is a band of fabric or
leather that is positioned around the patient’s
waist. During transfers or ambulation, the health
care worker can grasp the transfer belt to provide
additional support for the patient (figure 22-15).
The transfer belt helps provide the patient with a
sense of security and helps to stabilize the
FIGURE 22-15 A transfer belt can provide
support for the patient during transfers or
patient’s center of balance. Some important facts
ambulation.
to remember when ambulating a patient with a
transfer belt include the following:
♦ The transfer belt must be the proper size. It crutches require good upper body and arm
should fit securely around the waist for sup- strength, and a good sense of balance and
port but must not be too tight for comfort. coordination.
♦ Some transfer belts contain loops that are ♦ Forearm or Lofstrand crutches (figure 22-16B):
grasped when ambulating the patient. If loops These crutches attach to forearms, are used
are not present, an underhand grasp should for patients with weakness or paralysis in both
be used to hold on to the belt during ambula- legs, are recommended for patients who need
tion. The underhand grasp is more secure crutches permanently or for a long period of
than grasping the belt from the top, because time, and require upper arm strength and
the hands are less likely to slip off the belt. good coordination.
♦ The belt should be grasped at the back during ♦ Platform crutches (figure 22-16C): These
ambulation, and the health care worker should crutches are used for patients who cannot grip
walk slightly behind the patient. When assist- handles of other crutches or bear weight on
ing a patient to stand, or during transfers such their wrists and hands. They do not require as
as transferring a patient to a wheelchair, grasp much upper body strength, but do require a
the belt on both sides while facing the good sense of balance and coordination. They
patient. require that elbows be flexed at a 90-degree or
right angle so the patient can bear weight on
♦ The transfer belt is applied over the patient’s the forearm.
clothing. It should not be applied over bare
skin because it can irritate the skin. The following points should be observed
when fitting crutches to a patient.
The use of a transfer belt is contraindicated in
patients who have an ostomy, gastrostomy tube, ♦ The patient should wear walking shoes that fit
abdominal pacemaker, severe cardiac or respira- well and provide good support. The shoes
tory disease, fractured ribs, or recent surgery on should have low, broad heels approximately
the lower chest or abdominal area. It is also con- 1–11⁄2 inches high and nonskid soles.
traindicated for pregnant women. ♦ The crutches should be positioned 4–6 inches
in front of and 4–6 inches to the side of the
patient’s foot (figure 22-17).
CRUTCHES ♦ The length of axillary crutches should be
Crutches are artificial supports that assist a adjusted so that there are 2 inches between
patient who needs help walking. Crutches are the armpit and the axillary bar of the crutch
usually prescribed by a physician. A therapist or (figure 22-18).
other authorized individual fits the crutches to ♦ The handpieces of axillary or forearm crutches
the patient and teaches the appropriate gait. In should be adjusted so that each elbow is flexed
addition, exercises to strengthen the muscles of at a 25- to 30-degree angle.
the shoulders, arms, and hands are frequently
prescribed by the physician or therapist. Health Some of the more common crutch-walking
care workers should be aware of the criteria for gaits are described. The gait taught by the thera-
fitting crutches and of the gaits so that they can pist or authorized person depends on the injury
properly ambulate patients. and the patient’s condition.
There are three main types of crutches: ♦ Four-point gait: Used when both legs can bear
♦ Axillary crutches (figure 22-16A): These some weight. It is a slow gait. Patients often
crutches are made of wood or aluminum and are taught the four-point gait as the first gait
are used for patients who need crutches for a and are then taught faster gaits when this one
short period of time. The patient must be is mastered.
taught to bear weight on the hand bars instead ♦ Two-point gait: Often taught after the four-
of the axillary supports. If pressure is applied point gait is mastered. It is a faster gait and is
on the axillary bar, it can injure axillary blood usually used when both legs can bear some
vessels and nerves. They are not recommended weight. The two-point gait is closest to the
for weak or elderly patients since axillary natural rhythm of walking.
942 CHAPTER 22
FIGURE 22-16A A patient using FIGURE 22-16B Forearm or FIGURE 22-16C Platform
an axillary crutch must be taught to Lofstrand crutches are recom- crutches are used by patients who
bear weight on the hand bars mended for patients who need cannot grip the handles of other
instead of on the axillary supports. crutches permanently or for a long crutches or bear weight on the
period of time. wrists and hands.
6"
4"
FIGURE 22-18 The length of axillary crutches

FIGURE 22-17 Crutches should be positioned should be adjusted so that there are 2 inches
4–6 inches in front of and 4–6 inches to the side of between the axillary area and the top of the
the patient’s foot. crutches.
♦ Three-point gait: Used when only one leg can

bear weight. It too is a gait taught initially.
♦ Swing-to gait: This is a more rapid gait. It is
taught after other gaits are mastered, in most
cases. It requires that the patient have more
shoulder and arm strength.
♦ Swing-through gait: This is the most rapid
gait. However, it requires the most strength
and skill. It is usually taught as a more advanced
method of crutch walking.
CANE
A cane is an assistive device that provides bal-
ance and support. There are several different
types of canes (figure 22-19A). Standard canes
are single-tipped canes. They can have curved
handles, T-handles, or J-handles with a handgrip.
Tripod canes with three tips and quad canes with FIGURE 22-19B A walkcane has four legs and a
four tips provide a wider base of support and handlebar that the patient can grip. (Courtesy of
more stability for the patient. A walkcane, also Sunrise Medical)
called a Hemiwalker, has four legs and a handle-
bar that the patient can grip (figure 22-19B). It is
used with patients who have hemiplegia, or
paralysis on one side of the body. The bottom
tip(s) of all canes should be fitted with a 1-inch
rubber-suction tip to provide traction and pre-
vent slipping. Basic principles for using canes
include:
♦ A cane is used on the unaffected (good) side
(figure 22-19C). In this way, a wider base of
support is provided to increase stability. This
prevents the patient from leaning toward the
FIGURE 22-19C A cane is used on the unaf-

FIGURE 22-19A Different types of canes: (A) fected (good) side to provide a wider base of
quad canes; (B) single-tipped canes. support.
944 CHAPTER 22
cane and falling because of the weak or injured ♦ All legs of the walker should be fitted with rub-
leg. In addition, in normal walking, the leg and ber tips to prevent slipping.
opposite arm move together, so the cane and
leg will follow the same pattern. CAUTION: The patient should be cautioned
against sliding the walker. A sliding tech-
♦ Canes must be correctly fitted. The bottom tip nique may be dangerous because it can eas-
of the cane should be positioned approxi- ily tip over the walker. Most walkers are
mately 6–8 inches from the side of the unaf- made of lightweight aluminum, so most
fected foot. The cane handle should be level patients are capable of lifting them.
with the top of the femur at the hip joint. The
patient’s elbow should be flexed at a 25- to 30- CAUTION: Patients must also be cautioned
degree angle. against using the walker as a transfer device.
If they try to hold on to the walker while get-
♦ Several gaits for cane walking can be taught. ting out of bed or up from a chair, the walker
In a two-point gait, the patient is taught to
can tip forward, causing the patient to fall.
move the cane and affected leg together, and
Patients should be taught how to use their
then move the unaffected leg. In a three-point
arms to push against the bed or arms of a
gait, the patient is taught to move the cane,
chair to rise to a standing position.
then the affected or involved leg, and finally
the unaffected leg. The therapist or other
authorized person determines the correct
gait. AMBULATION
PRECAUTIONS
WALKER CAUTION: It is essential that the health care
A walker is a four-legged device that provides worker remain alert at all times when ambu-
support. Walkers are available in several styles, lating a patient. Always walk on the patient’s
including standard, folding, rolling, and platform. weak side and slightly behind the patient,
Rolling walkers have wheels and are easily pushed and be alert for signs that the patient may
by a patient who uses a walker primarily for bal- fall. If the patient starts to fall, do not try to
ance. However, if a patient leans on the walker for hold the patient in an upright position. Use
support, the wheels can be dangerous because your body to brace the patient, if at all pos-
the walker may move away from the patient, sible. Keep your back straight, bend from
causing the patient to fall. Some rolling walkers the hips and knees, maintain a broad base
have breaks on the wheels that lock automatically of support, and try to grasp the patient
when weight is placed downward on the walker. under the axillary (armpit) areas. If the
The patient must be evaluated carefully before a
rolling walker is used.
Walkers often are used for weak patients who
have a poor sense of balance even though no leg
injuries may be present. To use a walker, patients
must be strong enough to hold themselves
upright while leaning on the walker. Basic prin-
ciples for using a walker include:
♦ The walker should be fitted to the patient. The
handles should be level with the top of the
femurs at the hip joints. Each elbow should be
flexed at a 25- to 30-degree angle.
♦ The patient must be taught to lift the walker
and place it in front of the body. It should be
positioned so that the back legs of the walker FIGURE 22-20 Ease a falling patient to the floor
are even with the toes of the patient. The as slowly as possible. Try to protect the patient’s
patient then walks “into” the walker. head and neck.
patient is wearing a transfer belt, keep a firm occurred, most agencies require a written
hold on the belt. The patient should be incident report. Follow agency policy for
eased to the floor as slowly as possible (fig- correct documentation of the incident.
ure 22-20). The patient’s head and neck
should be protected, and the head should STUDENT: Go to the workbook and complete
be prevented from striking the floor. Stay the assignment sheet for 22:2, Ambulating Patients
with the patient and call for help. Patients Who Use Transfer (Gait) Belts, Crutches, Canes, or
should not be moved until they have been Walkers. Then return and continue with the pro-
examined for injuries. After a fall has cedures.
PROCEDURE 22:2A
Ambulating a Patient
with a Transfer (Gait)
Belt
Transfer or gait belt, pen or pencil
Procedure
1. Check orders or obtain authorization
from your immediate supervisor for
ambulating the patient.
2. Assemble supplies.
3. Knock on the door and pause before FIGURE 22-21A Position the transfer belt
entering. Introduce yourself. Identify around the patient’s waist and on top of the
the patient and explain the procedure. clothing.
4. Close the door and screen the unit to 9. Tighten the belt so that it fits snugly;
provide privacy. secure the clasp or buckle. Place three
5. Wash hands. to four fingers under the belt to make
sure it is not too tight (figure 22-21B).
6. Lock the wheels on the bed to prevent Make sure the belt is comfortable and
movement. Lower the siderail on the does not interfere with breathing. On a
side where you are working. female patient, make sure the breasts
7. Assist the patient into a sitting position. are not under the belt.
If the patient is wearing bedclothes, put 10. Put shoes or slippers on the patient. For
a robe on the patient. the most security, shoes should be worn.
8. Check to be sure the transfer belt is the The shoes should have low, broad heels
correct size. Position the belt around the approximately 1–11⁄2 inches high and
patient’s waist and on top of the cloth- nonskid soles. Make sure the patient’s
ing (figure 22-21A). Position the buckle feet are on the floor. If the patient’s feet
or clasp so that it is slightly off center in are not on the floor, move the patient
the front. Make sure the belt is smooth closer to the side of the bed or edge of a
and free of wrinkles. chair.
946 CHAPTER 22
PROCEDURE 22:2A
12. To ambulate the patient, support the
patient in a standing position. Keep one
hand on one side of the belt while mov-
ing the other hand to the loops or the
back of the belt. Then, move the second
hand from the side to the loops or the
back of the belt while you move behind
the patient.
CAUTION: Keep one hand firmly on the
belt at all times when changing posi-
tion.
13. Ambulate the patient. Encourage the
patient to walk slowly and use handrails,
FIGURE 22-21B Check the transfer belt to if available. Walk slightly behind the
make sure it is not too tight. patient at all times and keep a firm,
underhand grip on the belt or keep your
hands firmly in the loops.
NOTE: If the patient has a weak side,
position yourself on the patient’s weak
side.
14. If the patient starts to fall, keep a firm
grip on the belt. Use your body to brace
the patient; Keep your back straight (fig-
ure 22-22). Gently ease the patient to
FIGURE 22-21C Place your hands under the

sides of the belt and use proper body mechan-
ics as you help the patient to a standing posi-
tion.
11. Assist the patient to a standing position.

Face the patient and get a broad base of
support. Grasp the loops on the side of
the belt or place your hands under the
sides of the belt. Ask the patient to assist
by pushing against the bed with his/her
hands at a given signal, such as “one,
two, three, stand.” Bend at your knees
and give the signal for the patient to
stand. Keep your back straight and FIGURE 22-22 Keep your back straight and
straighten your knees as the patient use your body to brace the patient if the patient
stands (figure 22-21C). starts to fall.
PROCEDURE 22:2A
the floor, taking care to protect his or 19. Report and/or record all required infor-
her head. Stay with the patient and call mation on the patient’s chart or the
for help. Do not try to stand the patient agency form, for example, date; time;
up until help arrives and the patient has ambulated with a transfer belt, walked
been examined for injuries. down to lounge and back; and your sig-
nature and title. Report any problems
15. When ambulation is complete, assist
immediately.
the patient in returning to bed. Remove
the transfer belt.
comfortable and in good body align- Practice
ment. Elevate the siderails (if indicated), Go to the workbook and use the
lower the bed to its lowest level, place evaluation sheet for 22:2A,
the call signal and supplies within easy Ambulating a Patient with a
reach of the patient, and leave the area Transfer (Gait) Belt, to practice this
neat and clean. procedure. When you believe you
17. Replace all equipment. have mastered this skill, sign the
18. Wash hands. for further action.

PROCEDURE 22:2B
and that the tips are not worn down or
Ambulating a Patient torn. Check to be sure the axillary bars
Who Uses Crutches and hand rests are covered with pad-
ding.
Equipment and Supplies NOTE: Foam-rubber pads are usually
placed on crutches.
Adjustable crutches, pen or pencil
Procedure entering. Introduce yourself. Identify
1. Check orders or obtain authorization 5. Wash hands.
from your immediate supervisor. Ascer-
tain which gait the therapist taught the 6. Help the patient put on good walking
patient. shoes. The shoes should have low, broad
heels approximately 1–11⁄2 inches high
2. Assemble equipment. and nonskid soles.
3. Check the crutches. Make sure there are 7. Place a transfer (gait) belt on the patient.
rubber-suction tips on the bottom ends Use an underhand grasp on the belt and
948 CHAPTER 22
PROCEDURE 22:2B
assist the patient to a standing position.
Advise the patient to bear his or her
weight on the unaffected leg. Position
the crutches correctly.
8. Check the fit of the crutches.
a. Position the crutches 4–6 inches in
front of the patient’s feet.
b. Move the crutches 4–6 inches to the
sides of the feet.
c. Make sure there is a 2-inch gap
between the axilla (armpit) and the
axillary bar or rest. If the length must Move Move
Move Move
be adjusted, check with your imme- right left left right
diate supervisor. crutch. foot. crutch. foot.
d. Each elbow must be flexed at a 25- to FIGURE 22-23 Four-point gait for crutches.
30-degree angle. If the hand rests NOTE: This is a slow gait taught initially
must be adjusted to achieve this when both legs can bear weight.
angle, check with your immediate
supervisor. 11. Three-point gait (figure 22-24):
NOTE: In some agencies, the trained a. The patient can bear weight on one
health care worker is permitted to adjust leg only. Start the patient in a stand-
the crutches as necessary. The adjusting position, with crutches at the
ments are then checked by the therapist sides.
or other authorized person. Follow your b. Advance both crutches and the weak
agency’s policy. or affected foot.
9. Assist the patient with the required gait.
The gait used depends on the patient’s
injury and condition, and is determined
by the therapist or other authorized per-
son.
CAUTION: Remain alert at all times. Be
ready to catch the patient if there are
any signs of falling.
10. Four-point gait (figure 22-23):
a. The patient can bear weight on both Affected leg
legs. Start the patient in a standing
position, with crutches at the sides.
b. Move the right crutch forward.
c. Move the left foot forward.
Stand with Move both Move
d. Move the left crutch forward. both feet crutches unaffected
together. together with leg.
e. Move the right foot forward. affected leg.
FIGURE 22-24 Three-point gait for crutches.
PROCEDURE 22:2B
c. Transfer the patient’s body weight b. Balance weight on foot or feet. Move
forward to the crutches. both crutches forward.
d. Advance the unaffected, or good, c. Transfer weight forward.
foot forward.
d. Use shoulder and arm strength to
NOTE: This is a slow gait taught initially swing feet up to crutches.
when only one leg can bear weight.
NOTE: This is a more rapid gait and
12. Two-point gait (figure 22-25): requires more shoulder and arm
strength and a good sense of balance
a. The patient can bear weight on both
and coordination.
legs. Start with the crutches at the
sides. 14. Swing-through gait (figure 22-26):
b. Move the right foot and left crutch a. One or both of the patient’s legs can
forward at the same time. bear weight. Start with the crutches
at the sides. Balance weight on foot
c. Move the left foot and right crutch
or feet.
forward at the same time.
b. Advance both crutches forward at
NOTE: This is a more advanced and a
the same time.
more rapid gait used when the four-
point gait has been mastered. c. Transfer weight forward.
NOTE: The two-point gait is closest to d. Use shoulder and arm strength to
the natural rhythm of walking. swing up to and through the crutches,
stopping slightly in front of the
13. Swing-to gait:
crutches.
a. One or both of the patient’s legs can
NOTE: This is the most rapid and
bear weight. Start with the crutches
advanced gait. It requires a great deal of
at the sides.
Stand with Move one leg Move other Stand with Move both Move both legs
both feet together with leg with both feet crutches. by swinging
together. one crutch on opposing together. them forward.
opposite side. crutch. FIGURE 22-26 Swing-through gait for
FIGURE 22-25 Two-point gait for crutches. crutches.
950 CHAPTER 22
PROCEDURE 22:2B
shoulder and arm strength. It also elevate the siderails (if indicated), lower
requires an excellent sense of balance the bed to its lowest level, place the call
because at one point only the crutches signal and other supplies within easy
are in contact with the ground. reach of the patient, and leave the area
neat and clean.
15. When using crutches, the patient must
not rest his or her body weight on the 20. Wash hands.
axillary rests. Shoulder and arm strength
should provide movement on the
crutches.
CAUTION: Warn the patient that nerve ambulated with crutches, walked down
damage can occur if weight is supported the hall two times using two-point gait,
constantly on the axillary rest. no problems noted; and your signature
and title. Report any problems immedi-
16. Check to make sure that the patient is
ately.
not moving too far forward at one time.
Distances should be limited. If the
patient attempts to move the crutches
too far forward, he or she can very easily
lose balance and fall forward.
17. Check the patient’s progress. Report the
Practice
progress to the therapist or your imme- evaluation sheet for 22:2B,
diate supervisor. The therapist will
Ambulating a Patient Who Uses
determine when to teach the patient
Crutches, to practice this procedure.
more advanced gaits.
18. When the patient is finished using the mastered this skill, sign the sheet
crutches, replace all equipment. and give it to your instructor for
19. Assist the patient back to bed or posi- further action.
tion the patient in a chair. Remove the
transfer belt. Observe all checkpoints
before leaving the patient. Make sure Final Checkpoint Using the criteria
the patient is comfortable and in good listed on the evaluation sheet, your
body alignment. If the patient is in bed, instructor will grade your performance.
PROCEDURE 22:2C
Ambulating a Patient Procedure
Who Uses a Cane 1. Check orders or obtain authorization
from your immediate supervisor. Ascer-
Equipment and Supplies tain which gait the therapist taught the
patient.
Adjustable cane, pen or pencil
PROCEDURE 22:2C
3. Check the cane. Make sure the bottom
Three-point gait
has a rubber-suction tip. If the patient
needs extra stability, use a tripod (three- 1 2
legged) or quad (four-legged) cane. 3
5. Wash hands.
6. Help the patient put on good walking
shoes. The shoes should have low, broad
KEY
and nonskid soles. walker or cane
7. Place a transfer (gait) belt on the patient.
Use an underhand grasp on the belt and
assist the patient to a standing position. affected leg
Advise the patient to bear his or her
weight on the unaffected leg.
8. Check the height of the cane: unaffected leg
a. Position the cane on the unaffected

(good) side and approximately 6–8 When no affected leg is shown,
inches from the side of the foot. weight bearing is equal on both legs
b. The top of the cane should be level FIGURE 22-27A Three-point gait for canes.
with the top of the femur at the hip
joint.
b. Move the weak or affected foot for-
c. The patient’s elbow should be flexed ward.
at a 25- to 30-degree angle.
c. Transfer the weight to the affected
NOTE: If the height of the cane needs foot and cane. Bring the unaffected
adjustment, follow agency policy. In foot forward.
some agencies, only the therapist
For a two-point gait (figure 22-27B):
adjusts canes. In other agencies, the
trained health care worker can adjust a. Balance the weight on the strong or
canes. unaffected foot.
9. Instruct the patient to use the cane on b. Move the cane and the weak or
the good, or unaffected, side. affected foot forward. Keep the cane
fairly close to the body to prevent
NOTE: This prevents leaning toward the
leaning.
weak or affected side and provides a
broader base of support. c. Transfer body weight forward to the
cane.
10. Assist the patient with the gait ordered.
For a three-point gait (figure 22-27A): d. Move the good, or unaffected, foot
forward.
a. Balance the body weight on the
strong or unaffected foot. Move the CAUTION: Remain alert at all times. Be
cane forward approximately 12–18 ready to catch the patient if there are
inches. any signs of falling.
952 CHAPTER 22
PROCEDURE 22:2C
are recommended to prevent leaning
Two-point gait
and/or loss of balance.
1 2 1 13. Note the patient’s progress. Pay particu-
lar attention to any problems the patient
experiences during ambulation. Report
this information to your immediate
supervisor or the therapist.
14. Assist the patient back to bed or posi-
transfer belt.
KEY
walker or cane the patient. Make sure the patient is
ment. If the patient is in bed, elevate the
affected leg siderails (if indicated), lower the bed to
its lowest level, place the call signal and
other supplies within easy reach of the
patient, and leave the area neat and
unaffected leg clean.
When no affected leg is shown,
weight bearing is equal on both legs 17. Wash hands.
FIGURE 22-27B Two-point gait for canes.
ambulated with tripod cane, walked to
NOTE: Maintain an underhand grasp visitor’s lounge and back to room, no
on the transfer belt if the patient is not problems noted; and your signature and
steady. title. Report any problems immediately.
11. A common sequence to follow when

assisting the patient up and down stairs
is that of always starting with the good
(unaffected) leg: Practice
a. Step up with the unaffected leg. Go to the workbook and use the
b. Bring the cane and weak or affected Ambulating a Patient Who Uses a
leg up. Cane, to practice this procedure.
c. To go down steps, reverse this proce- When you believe you have
dure. Step down on the good leg and mastered this skill, sign the sheet
follow with the cane and affected or and give it to your instructor for
weak foot. further action.
NOTE: Remember this sequence by say-
ing, “Good Guys Go First.”
12. When walking with a cane, the patient listed on the evaluation sheet, your
should take small steps. Smaller steps instructor will grade your performance.
PROCEDURE 22:2D
9. Start with the walker in position. The
Ambulating a Patient patient should be standing “inside” the
Who Uses a Walker walker.
10. Tell the patient to lift the walker and
Equipment and Supplies place it forward so that the back legs of
the walker are even with the patient’s
Adjustable walker, pen or pencil
toes.
Procedure CAUTION: Tell the patient to avoid slid-
ing the walker. The walker could fall for-
1. Check orders or obtain authorization ward and cause the patient to fall.
from your immediate supervisor for 11. Instruct the patient to transfer his or her
ambulating the patient. weight forward slightly to the walker.
2. Assemble equipment. 12. Instruct the patient to use the walker for
3. Check the walker. Make sure rubber- support and to walk “into” the walker.
suction tips are secure on all of the legs. Do not allow the patient to “shuffle” his
Check for rough or damaged edges on or her feet (figure 22-28).
the hand rests.
5. Wash hands.
6. Help the patient put on good walking
shoes. The shoes should have low, broad
and nonskid soles.
7. Place a transfer (gait) belt on the patient.
Use an underhand grasp on the belt and
assist the patient to a standing position.
Position the walker correctly and ask the
patient to grasp the hand rests securely.
8. Check the height of the walker to see
whether the following requirements are
met:
a. The hand rests are level with the tops
of the femurs at the hip joints.
b. The elbows are flexed at 25- to 30-
degree angles.
NOTE: If the height of the walker needs
adjustment, follow agency policy. In
some agencies, only the therapist makes
such adjustments. In other agencies, a FIGURE 22-28 Instruct the patient to use the
trained health care worker may adjust walker for support while walking “into” the
walkers. walker.
954 CHAPTER 22
PROCEDURE 22:2D
13. Repeat steps 10–12. While the patient is patient, and leave the area neat and
using the walker, walk to the side and clean.
slightly behind the patient. Be alert at all
times. Be ready to catch the patient if
there are any signs of falling. 19. Wash hands.
NOTE: If the patient has a weak side, 20. Report and/or record all required infor-
position yourself on the patient’s weak mation on the patient’s chart or the
side. agency form; for example, date; time;
ambulated with walker, walked down
14. Check constantly to make sure the
the hall and back two times, needs
patient is lifting the walker to move it
encouragement to pick up walker and
forward. Also make sure the patient is
not slide it; and your signature and title.
placing the walker forward just to his or
Report any problems immediately.
her toes and not attempting too large a
step.
15. Note the patient’s progress. Pay particu-
lar attention to any problems the patient
experiences during ambulation. Report Practice
this information to your immediate Go to the workbook and use the
supervisor or the therapist. evaluation sheet for 22:2D,
Ambulating a Patient Who Uses a
16. Assist the patient back to bed or posi-
Walker, to practice this procedure.
transfer belt.
17. Observe all checkpoints before leaving and give it to your instructor for
the patient. Make sure the patient is further action.
ment. If the patient is in bed, elevate the
siderails (if indicated), lower the bed to Final Checkpoint Using the criteria
its lowest level, place the call signal and listed on the evaluation sheet, your
other supplies within easy reach of the instructor will grade your performance.
presses, packs, and soaks. These applications

22:3 INFORMATION are more penetrating than are dry cold appli-
cations.
Administering Heat/Cold
Applications ♦ Dry cold applications are cold and dry against
the skin. Examples are ice bags, ice collars,
As a health care worker, you may be responsible hypothermia blankets, and similar devices.
for administering a variety of heat and cold appli-
♦ Ice bags or collars are special containers
cations. Some of the main principles involved are
filled with ice. Most health care facilities use
described in this section.
disposable bags to prevent the spread of infec-
Cryotherapy is the use of cold for treatment.
tion. A hypothermia blanket, also called a
Cold applications are administered to relieve
thermal blanket, contains coils that are filled
pain, reduce swelling, reduce body temperature,
with cool fluid. It is used to reduce high body
and control bleeding.
temperatures. A rectal probe is usually used to
♦ Moist cold applications are cold and moist or monitor the patient’s temperature. When the
wet against the skin. Examples are cold com- patient’s temperature reaches a preset level,
the blanket decreases the circulation of the

cooling fluid.
Thermotherapy is the use of heat for treat-
ment. Heat applications are administered to
relieve pain, increase drainage from an infected
area, stimulate healing, increase circulation to an
area, combat infection, and relieve muscle
spasms or increase muscle mobility before exer-
cise.
♦ Moist heat applications are warm and wet
against the skin. These applications are more
penetrating and more effective in relieving
pain in deeper tissues than are dry heat appli-
cations. Examples are the sitz bath, hot soaks,
compresses, hydrocollator packs, and paraffin
wax treatments.
♦ Sitz baths provide warm moist heat to the
perineal and rectal area. They are used post-
partum (after birth) and after rectal surgery to
provide comfort and promote healing.
♦ Hydrocollator packs are gel-filled packs
that are warmed in a water bath at a tempera-
ture of 150–170°F. The gel maintains the
warmth for approximately 30–40 minutes, and
the pack can be contoured to fit smoothly over FIGURE 22-29 Hydrocollator packs are gel-filled
any area of the body (figure 22-29). The pack packs that are warmed in a water bath. (Courtesy of
must be covered with a thick terry cloth or Briggs Corporation, Des Moines, IA)
flannel cover before being applied to the skin.
Hydrocollator packs are frequently used prior
to ROM exercises. (figure 22-31). Usually, a rectal probe is used
to monitor the patient’s temperature. The unit
♦ Paraffin wax treatments are often used for automatically circulates warm or cool fluid or
chronic joint disease, such as arthritis, or prior
air to maintain a preset temperature.
to ROM exercises. A mixture of paraffin and a
small amount of mineral oil are heated to the ♦ Aquathermia pads, also called aquamatic
melting point. The physical therapist dips the units, are smaller pads that contain coils that
patient’s hand(s) or other body part into the fill with warm water. A control unit maintains
warm paraffin three or four times to create a a constant preset temperature of the water.
“glove” of wax (figure 22-30A). The wax is left Heat and cold applications are effective
in place for 20–30 minutes before being peeled because of the reactions they cause in the
off (figure 22-30B). blood vessels.
♦ Dry heat applications are warm and dry against ♦ Heat applications cause vasodilation. The
the skin. Examples are warm-water bags, heat- blood vessels in the area become larger
ing pads, thermal blankets, aquamatic pads or (dilated). More blood comes to the area. There-
aquathermia pads, and heat lamps. fore, more oxygen and nutrients are available
♦ Warm-water bags are special containers to stimulate healing. Heat applications ease
filled with warm water to provide heat to body pain by allowing the blood to carry away fluids
parts. Most health care agencies use dispos- that cause inflammation and pain.
able bags to prevent the spread of infection. ♦ Cold applications cause vasoconstriction.
♦ Thermal blankets contain coils that can be The blood vessels become smaller (con-
filled with air or fluid to warm or cool a patient stricted). Less blood comes to the area. Swell-
956 CHAPTER 22
ing decreases because fewer fluids are present.

The cold also has a numbing effect, which
decreases local pain.
A physician’s order is required for a heat or
cold application. The order should state the
type of application, duration of treatment, tem-
perature (if not standard), and area of applica-
tion. In some states and agencies, health care
assistants are not allowed to administer heat or
cold applications. It is important to check your
agency’s policy and be aware of your legal respon-
sibilities.
CAUTION: The patient must be checked
frequently when an application is in place.
Color and temperature of the skin, amount of
pain and bleeding, effect on circulation, and
FIGURE 22-30A A body part is dipped into the other signs and symptoms must be noted. Spe-
paraffin bath three or four times to create a layer of cial attention must be given to infants, young
warm wax on the skin. (Courtesy of Briggs Corpora- children, and elderly patients, because the skin of
tion, Des Moines, IA) these patients is less resistant and burns or inju-
ries can occur rapidly. Metal objects, such as
rings, bracelets, necklaces, watches, and zippers,
readily conduct heat or cold. Patients should be
asked to remove all metal objects in the treated
area before a heat or cold application is adminis-
tered. When administering heat or cold applica-
tions, the rubber or plastic should never come in
contact with the skin. All rubber or plastic appli-
cations should be covered with a towel or special
cloth cover. If any abnormal symptoms are noted,
the application should be discontinued and the
immediate supervisor notified. The health care
worker must be alert at all times and observe all
FIGURE 22-30B After the wax has been in place safety precautions when administering heat and
for 20–30 minutes, it is peeled off and discarded. cold applications.
14:4) must be observed if any contact with
blood, body fluids, secretions, or excretions is
possible. An example is a moist heat application
placed on a draining wound. Gloves must be
worn. Hands must be washed frequently and are
always washed immediately after removing
gloves. A mask and eye protection must be worn
if splashing or spraying of body fluids is possible.
A health care worker must always use proper pre-
cautions to prevent the spread of infection.

FIGURE 22-31 A thermal blanket contains coils the assignment sheet for 22:3, Administering Heat/
that are filled with water or air to warm or cool the Cold Applications. Then return and continue with
body. the procedures.
PROCEDURE 22:3A
Applying an Ice Bag
or Ice Collar
Ice collar or ice bag and cap, cover or towel,
tape, ice in basin, scoop or paper cup, pen or
pencil
Procedure
supervisor for the application.
3. Wash hands.
4. Fill the ice bag or collar with water.
Check for leaks. Empty if no leaks are
present.
NOTE: Ice bags come in various sizes for
different parts of the body. An ice collar
is narrow and is used on the throat. FIGURE 22-32A Fill the ice bag half full.
5. Use the scoop to fill the ice bag or collar
half full (figure 22-32A). To assist in fill-
ing, a paper cup with the bottom cut out
can be placed in the neck of the bag and
used as a funnel. Ice can then be scooped
into the bag.
NOTE: If ice cubes are used, rinse them
with water to remove sharp edges.
NOTE: In some agencies, disposable
cold packs are used. To activate the
chemicals in the cold pack, squeeze the
pack or strike it against a solid surface. It
does not need to be filled with ice. A
cover must still be placed on the dispos-
able cold pack because the plastic and
cold can injure the skin.
CAUTION: Chemical ice packs are not
recommended for use on the face or
head because of the danger of leaking
chemicals.
6. Place the bag on a table or flat surface.
Push gently on the bag to expel all air FIGURE 22-32B Push gently on the bag to
(figure 22-32B). Tighten the cap. expel all air before tightening the cap.
958 CHAPTER 22
PROCEDURE 22:3A
NOTE: If a rubber ring is present on the continuous application is ordered; in
cap, make sure the ring is secure; it pre- others, a specific time period, such as 20
vents leakage. minutes, is ordered. Remove the bag
when the designated time has elapsed.
7. Wipe the outside of the bag dry.
15. Carefully check the condition of the
8. Place a cover on the bag. If an ice bag or
patient’s skin. Note any comments the
ice collar cover is not available, use a
patient makes about the treatment.
towel. Tape the towel in place.
Report these to your supervisor.
CAUTION: The bag must be covered.
The rubber or plastic and the extreme
cold can injure the skin.
9. Knock on the door and pause before rails (if indicated), lower the bed to its
entering. Introduce yourself. Identify lowest level, place the call signal and
the patient. Explain the procedure. supplies within easy reach of the patient,
10. Wash hands. Put on gloves if necessary. and leave the area neat and clean.
CAUTION: Wear gloves and observe 17. If the ice bag is disposable, discard it. If
standard precautions if the area to be the ice bag is not disposable, empty it
treated has any drainage of blood, body and clean it thoroughly. Wipe it with a
fluids, secretions, or excretions. disinfectant, rinse, and dry. Inflate it with
air before storing. This prevents the sides
11. Place the ice bag gently on the affected from sticking. Replace all equipment.
area as ordered. If the cap is metal, make
sure it is not on the patient’s skin. 18. Remove gloves if worn. Wash hands.
NOTE: Metal will intensify the cold. If 19. Report and/or record all required infor-
the cold metal cap rests on the patient’s mation on the patient’s chart or the
skin, an injury can occur. agency form; for example, date; time;
ice bag applied to right forearm for 20
12. Make sure the patient is comfortable minutes, patient states arm feels better;
and the ice application is positioned and your signature and title. Report any
correctly before leaving. Place the call unusual observations immediately.
signal within easy reach of the patient.
Remove gloves, if worn, and wash hands
13. Recheck the patient at least every 10
minutes. Make sure the bag is cold and Practice
refill it as needed. Check the condition Go to the workbook and use the
of the skin. Check for pale or white skin, evaluation sheet for 22:3A, Applying
cyanosis (bluish color), or a mottled an Ice Bag or Ice Collar, to practice
appearance. Ask the patient about this procedure. When you believe
numbness and pain. you have mastered this skill, sign
CAUTION: If the skin is mottled or very
discolored, or the patient complains of instructor for further action.
pain, remove the bag immediately and
inform your immediate supervisor.
14. Leave the ice application in place for the listed on the evaluation sheet, your
length of time ordered. In some cases, instructor will grade your performance.
PROCEDURE 22:3B
NOTE: Temperatures may vary. Follow
Applying a Warm- agency policy.
Water Bag NOTE: In some agencies, disposable
heat packs are used. To activate the
Equipment and Supplies chemicals in the heat pack, squeeze the
pack or strike it against a solid surface. It
Warm-water bag, cover or towel for bag, tape,
does not need to be filled with hot water.
measuring graduate or pitcher, bath ther-
A cover must still be placed on the dis-
mometer, pen or pencil
posable heat pack because the plastic
and heat can injure the skin.
Procedure
CAUTION: Chemical heat packs are not
1. Check physician’s orders or obtain recommended for use on the face or
authorization from your immediate head because of the danger of leaking
supervisor for the application. chemicals.
2. Assemble equipment. 6. Pour the measured hot water into the
warm-water bag. Fill the bag one-third
3. Wash hands.
to one-half full (figure 22-33B).
4. Check for leaks by filling the warm-
7. Expel remaining air by placing the
water bag with tap water or air. Expel
warm-water bag on a flat surface, lifting
the water or air if no leaks are present.
and holding the neck portion of the bag
5. Fill the pitcher with water at a tempera- upright, and pushing gently on the bag
ture of 110–120°F, or 43–49°C. Use the until the water reaches the neck (figure
bath thermometer to check the temper- 22-33C). Apply the screw cap or fold
ature (figure 22-33A). over the end.
CAUTION: The temperature should not NOTE: If the bag has a fold end, note the
exceed 120°F, or 49°C. letters A, B, and C. Fold A to B, B to C,
and C to seal.
8. Wipe the outside of the bag dry. Check
again for any signs of leaks.
FIGURE 22-33A Use a bath thermometer to

verify that the temperature of the water is 110– FIGURE 22-33B Fill the warm-water bag
120°F. one-third to one-half full.
960 CHAPTER 22
PROCEDURE 22:3B
11. Wash hands. Put on gloves if necessary.
standard precautions if the area to be
treated has any drainage of blood, body
fluids, secretions, or excretions.
12. Apply the bag gently to the affected area
as ordered. Make sure it is placed on top
of the area. Never place heat under the
body.
CAUTION: Do not allow any part of the
patient’s body to lie on top of the warm-
FIGURE 22-33C Expel air from the warm- water bag. Weight of the body part could
water bag by placing it on a flat surface and
intensify the heat.
gently pressing it until the water reaches the
neck of the bag. 13. Before leaving, check to be sure the
patient is comfortable and the bag is
CAUTION: Never use a warm-water bag properly positioned. Place the call sig-
or cap that leaks. The patient can be nal within easy reach of the patient.
scalded. Remove gloves, if worn, and wash hands
9. Place a cover on the warm-water bag before leaving the room.
(figure 22-33D). Use a standard cover, if 14. Recheck the patient at least every 10
available. If not, use a towel and tape the minutes. Refill the bag as needed to
towel in place. The towel should be maintain warm temperature. Note any
smooth and should completely cover pain, extreme redness, or other condi-
the warm-water bag. tions.
CAUTION: The warm-water bag must CAUTION: If signs of a burn are noted,
be covered to prevent injury to the skin. remove the application immediately
and report to your immediate supervi-
sor.
15. Remove the heat application when the
time ordered has elapsed. Closely check
the patient’s skin.
supplies within easy reach of the patient,
17. Discard a disposable heat pack. If the
FIGURE 22-33D Cover the warm-water bag warm-water bag is not disposable,
with a towel or standard cover. empty the warm-water bag and clean
PROCEDURE 22:3B
thoroughly. Wipe it with a disinfectant,
rinse, and dry. Fill it with air before stor-
ing. This keeps the sides from sticking
together. Replace all equipment. Practice
18. Remove gloves if worn. Wash hands. evaluation sheet for 22:3B, Applying
19. Report and/or record all required infor- a Warm-Water Bag, to practice this
mation on the patient’s chart or the procedure. When you believe you
agency form; for example, date; time; have mastered this skill, sign the
warm-water bag applied to right knee sheet and give it to your instructor
for 20 minutes, patient stated pain for further action.
relieved in knee; and your signature and
immediately.
PROCEDURE 22:3C
treated has any drainage of blood, body
Applying an fluids, secretions, or excretions.
Aquathermia Pad 5. Place the aquathermia control unit on a
solid table or stand. Check the cord.
NOTE: Aquathermia or aquamatic pads can
Attach the tubing to the main unit and
vary. Read the manufacturer’s instructions
aquathermia pad, if necessary.
before using.
NOTE: Follow specific manufacturer’s
Equipment and Supplies instructions. Some agencies use dispos-
able pads. Tubing must be attached to
Aquathermia unit and pad, cover, distilled these pads.
water, pen or pencil
6. Unscrew the reservoir cap on the top of
Procedure the unit. Use distilled water to fill the
unit to the fill line.
1. Check physician’s orders or obtain NOTE: Distilled water prevents forma-
authorization from your immediate tion of mineral deposits.
supervisor for the application.
7. Screw the cap in place and then loosen
2. Assemble equipment. it one-quarter turn. This allows for over-
3. Knock on the door and pause before flow of water and escape of steam.
entering. Introduce yourself. Identify 8. Plug in the cord. Set the desired temper-
the patient. Explain the procedure to ature by inserting the special key into
the patient. the center of the dial or follow manufac-
4. Wash hands. Put on gloves if necessary. turer’s instructions. Temperature is usu-
ally set at 95–105°F, or 35–41°C. Turn the
unit on.
standard precautions if the area to be
962 CHAPTER 22
PROCEDURE 22:3C
NOTE: Set the temperature according to the patient is comfortable. Place the call
physician’s orders or agency policy. signal within easy reach of the patient.
Remove gloves, if worn, and wash hands
CAUTION: After setting the tempera-
ture, remove the key and store it in a safe
area. Do not leave the key in position on 12. Recheck the patient at least every 10
the unit. Others could change or alter minutes. Note the condition of the skin.
the temperature. If the skin is red or shows evidence of
burns, or the patient complains of pain,
9. Check the pad for leaks. Also check that
remove the pad and inform your imme-
the unit is getting warm. Make sure the
diate supervisor.
tubing is not bent or kinked. Recheck
the level of water in the reservoir. A large 13. Refill the water unit with distilled water
amount of water is used when the pad is as necessary.
filled with water.
14. When the ordered time has elapsed,
10. Cover the pad (figure 22-34). If a custom remove the pad from the patient. Note
cover is not available, a pillowcase or the condition of the skin. Note the
towel can be used. Use tape to hold the patient’s comments to determine
cover in place. (Pins could puncture the whether the application was effective.
pad.)
NOTE: The physician’s orders may pre-
CAUTION: The pad must never be scribe continuous application of the
placed directly on the patient’s skin. It pad. If so, check the patient periodi-
can cause burns. cally.
11. Place the pad on the correct area as 15. Observe all checkpoints before leaving
ordered. Coil the tubing on the bed to the patient: position the patient in cor-
facilitate the flow of water through the rect body alignment, elevate the side-
tubing. Do not allow the tubing to hang rails (if indicated), lower the bed to its
below the level of the bed. Check that lowest level, place the call signal and
16. Empty the pad. Empty the control unit.
Clean all equipment thoroughly. Disin-
fect the pad and unit according to
agency policy or discard if disposable.
Replace all equipment.
CAUTION: Do not put the electric con-
trol unit in water.
17. Remove gloves, if worn. Wash hands.
aquathermia pad applied to left elbow
and forearm for 20 minutes, patient
stated pain relieved; and your signature
and title. Report any unusual observa-
FIGURE 22-34 Cover the aquathermia pad tions immediately.
before applying it to the patient.
PROCEDURE 22:3C
Practice
Go to the workbook and use the evaluation sheet for 22:3C, Applying an Aquathermia
Pad, to practice this procedure. When you believe you have mastered this skill, sign the
sheet and give it to your instructor for further action.
Final Checkpoint Using the criteria listed on the evaluation sheet, your instructor
will grade your performance.
PROCEDURE 22:3D
NOTE: A bath blanket can be used to
Applying a Moist drape the patient during the procedure.
Compress 6. Position an underpad or bed protector
near the area to be treated. This will
Equipment and Supplies keep the patient’s bedclothes and bed
linens dry.
Basin; bath thermometer; underpads or bed
protectors; washcloth, towel, or gauze pads 7. Fill the basin with water at the correct
(for compress); bath towel; plastic sheet; pen temperature. Use the bath thermometer
or pencil to check the temperature.
a. If a cold compress is to be applied, fill
Procedure the basin with cold water. Ice cubes
are sometimes added to the water.
1. Check physician’s orders or obtain Do not add ice cubes unless you are
authorization from your immediate told to do so.
supervisor for the application. b. If a hot compress is to be applied, fill
2. Assemble equipment. the basin with water at a temperature
3. Knock on the door and pause before of 100–105°F, or 37.8–41°C.
entering. Introduce yourself. Identify NOTE: Temperatures may vary. Follow
the patient. Explain the procedure to physician’s orders or agency policy.
the patient. 8. Put the compress (washcloth, towel, or
4. Wash hands. Put on gloves. gauze pad) in the water. Wring out the
CAUTION: Observe standard precau- compress to remove excess liquid (fig-
tions if any contact with blood or body ure 22-35A).
fluids is likely, such as when a compress 9. Apply the compress to the correct area
is applied to a draining wound. (figure 22-35B). Use a plastic sheet to
cover the area. Then wrap a bath towel
5. Screen the unit. Elevate the bed to a
around the treated area.
comfortable working height. Fold the
sheets back to expose the area to be NOTE: The plastic sheet helps keep the
treated. compress moist and hot or cold.
964 CHAPTER 22
PROCEDURE 22:3D
compress immediately and inform your
immediate supervisor.
12. Continue the treatment for the required
period of time as ordered by the physician
or per agency policy. Most compresses
are left in place for 15–20 minutes.
13. When the ordered time has elapsed,
remove the compress from the patient.
Note the condition of the skin. Note the
patient’s comments to determine
whether the application was effective.
FIGURE 22-35A After putting the compress rails (if indicated), lower the bed to its
in the water, wring it out to remove excess
liquid.
15. Clean and replace all equipment used.
Discard gauze pads used as compresses.
Place linen in a hamper or the laundry
area.
cold moist compresses applied to right
knee for 20 minutes, no change in skin
color noted, patient states knee still
hurts; and your signature and title. Report
any unusual observations immediately.
FIGURE 22-35B Apply the compress to the
correct area.
NOTE: An underpad or bed protector is
sometimes used instead of a plastic Practice
sheet. Go to the workbook and use the
evaluation sheet for 22:3D, Applying
10. An ice bag or aquamatic pad is some-
a Moist Compress, to practice this
times placed over the compress to help
maintain the temperature. Follow procedure. When you believe you
agency policy or physician’s orders. have mastered this skill, sign the
11. Check the compress at frequent inter- for further action.
vals. Change the compress and
remoisten it as necessary. Check the
condition of the skin under the com- Final Checkpoint Using the criteria
press. If the skin is discolored or the listed on the evaluation sheet, your
patient complains of pain, remove the instructor will grade your performance.
PROCEDURE 22:3E
Administering a Sitz
Bath
Sitz-bath chair, disposable unit, or tub; one to
two bath blankets; towels; gown; robe; slip-
pers; bath thermometer; pen or pencil
Procedure
supervisor for the treatment.
entering. Introduce yourself. Identify FIGURE 22-36B Stationary sitz-bath tubs are
the patient. Explain the procedure. Ask available in many health care facilities.
the patient to put on a hospital gown.
c. Fill the container on a portable unit
Assist as necessary.
with water at 105°F, or 41°C. Place the
4. Wash hands. container on a commode chair or
5. Prepare the sitz-bath unit: toilet (lift the seat before position-
ing), (figure 22-36C). Connect the
a. A sitz chair has an automatic temper- tubing to the container. Make sure
ature control, set at 105°F, or 41°C the holes on the tubing are facing the
(figure 22-36A). Fill the chair with
water. Plug in the cord. Drape the
bottom with a towel or bath blanket.
b. Fill a tub or sitz tub to the correct
level with water at 105°F, or 41°C (fig-
ure 22-36B). Place a towel or bath
blanket in the bottom of the tub.
FIGURE 22-36A The sitz chair has an

automatic control to maintain the correct FIGURE 22-36C A portable sitz-bath unit is
temperature while the patient is seated in the positioned on the base of the toilet after the
chair. seat is elevated.
966 CHAPTER 22
PROCEDURE 22:3E
sides of the container. Clamp the tub- to maintain the temperature at 105°F, or
ing with its clamp. Fill the bag with 41°C.
water at 110–115°F, or 43–46°C. 9. If the patient tolerates the procedure,
NOTE: Temperatures may vary. Follow leave the patient in the sitz bath for 20
physician’s orders or agency policy. minutes or the length of time ordered by
6. Position the patient in the sitz bath. the physician.
Raise the patient’s gown above the water 10. When the treatment is complete, assist
level. Make sure the perineal area is in the patient out of the chair, tub, or unit.
the water. Use bath blankets to cover the Dry the patient with a towel. Put clean,
patient’s legs and/or shoulders (figure dry clothing on the patient.
22-37). 11. Assist the patient in returning to bed.
NOTE: The gown can be removed if the 12. Observe all checkpoints before leaving
patient is in a tub. Drape the patient the patient: position the patient in cor-
with a bath blanket to prevent expo- rect body alignment, elevate the side-
sure. rails (if indicated), lower the bed to its
7. Observe the patient closely for signs of lowest level, position the call signal and
weakness or dizziness. supplies within easy reach of the patient,
CAUTION: If excessive weakness or diz- and leave the area neat and clean.
ziness is noted, discontinue the treat- 13. Clean and replace all equipment used.
ment and inform your immediate Wear gloves to disinfect the tub, sitz tub,
supervisor. or sitz chair according to agency policy.
8. If a portable unit is used, add water from Portable units are usually charged to the
the bag when the water in the container patient and kept in the patient’s unit.
gets cool. In a tub, drain some water and 14. Remove gloves. Wash hands.
then add additional water as necessary 15. Report and/or record all required infor-
sitz bath taken in sitz tub for 20 minutes,
patient states she feels much better; and
Practice
Administering a Sitz Bath, to
FIGURE 22-37 After the patient is seated in Final Checkpoint Using the criteria
the sitz bath, cover the patient’s legs and listed on the evaluation sheet, your
shoulders with a bath blanket. instructor will grade your performance.

A Jacuzzi bath to treat breast cancer?
Every year, more than 200,000 women are diagnosed with breast cancer. Options for
treatment include chemotherapy, radiation, and/or surgery. In addition to experiencing
stress and anxiety from dealing with the cancer, women usually experience side effects such
as nausea, vomiting, hair loss, and severe pain while undergoing treatment.
Scientists at Duke Comprehensive Cancer Center have developed a treatment method
that is less traumatic than standard treatments. Drugs used to treat cancer are placed inside
a liposome, a tiny fat bubble that creates a protective coating around the drugs. The woman
receiving treatment lies on her stomach on a massage type table with an opening that allows
the affected breast to rest in a pool of water. Radiofrequency energy warms the water and
breast tissue, similar to a Jacuzzi bath. The chemotherapy agent is injected by an intrave-
nous solution and the liposomes are drawn directly to the site of the tumor because the heat
tends to make the blood vessels by the tumor much more porous. This method allows scien-
tists to deliver much larger doses of chemotherapy directly to the tumor. In addition, it
decreases the amount of the drug that enters the heart, nerves, liver, and other body tissues
because these tissues are cooler than the warmed breast tissue. This helps prevent the nau-
sea, vomiting, and hair loss that results when cancer treatment drugs invade body tissues.
Early trials have shown that this method appears to be effective in reducing, and in some
cases even eliminating, breast tumors. Many women who took part in initial trials were able
to have a lumpectomy (surgical removal of the tumor) instead of a mastectomy (surgical
removal of the breast). Researchers are currently developing liposomes that are more heat
sensitive, so treatment can be restricted to the tumor site. Additional studies are also being
done with different types of breast cancers. Imagine a future when the treatment for breast
cancer is not only effective but easier to tolerate.
CHAPTER 22 SUMMARY Heat and cold applications are administered

for a wide variety of conditions. Careful observa-
tion of temperature and condition of the skin is
Physical therapy techniques are utilized by a essential to prevent injury to the patient. Again,
wide variety of health care workers. Physical correct techniques must be used at all times
therapy involves using physical means to treat when these applications are administered.
the patient. Physical therapy is frequently an important
Range-of-motion (ROM) exercises are done part of the patient’s treatment. By learning and
to maintain the health of the muscles and skel- understanding basic principles, the health care
etal system. They are frequently ordered for pa- worker can help provide this part of the patient’s
tients with limited ability to move. Each joint care.
and muscle in the body is moved through its full
ROM. By following the correct procedures and
using proper body mechanics, the health care
worker can help the patient maintain as much INTERNET SEARCHES
mobility as possible.
Proper techniques must also be used when
ambulating patients using transfer (gait) belts,
crutches, canes, or walkers. By understanding
the different gaits, proper ways of fitting the 1. Organizations: research physical therapy
devices to patients, and safety precautions, the careers, educational requirements, and duties
health care worker can provide support and at sites such as the American Athletic Trainer’s
guidance for patients relying on these aids. Association, American Physical Therapy
968 CHAPTER 22
Association, and the American Massage 4. You are ambulating a patient with a transfer
Therapy Association belt. The patient starts to fall. What do you do?
2. Physical therapy: research range-of-motion 5. Differentiate between a three-point and a two-
exercises, massage therapy, ultrasound therapy, point gait for canes.
cryotherapy, thermotherapy, and physical
6. What is the difference between moist heat and
therapy
dry heat? Give two (2) examples for each type
3. Suppliers: find suppliers of physical therapy of application.
equipment to compare the different types of
7. Define each of the following:
equipment available
a. vasodilation
b. vasoconstriction
REVIEW QUESTIONS 8. Identify five (5) safety measures or checkpoints
that must be observed whenever a heat or cold
application is applied to a patient.
1. What are the four (4) main types of range-of-
motion (ROM) exercises? How is each type
performed? For additional information on physical ther-
2. List eight (8) different types of joint move- apy careers, contact the following:
ments and briefly describe each movement. ♦ American Physical Therapy Association
111 North Fairfax Street
3. What are the basic rules that must be followed
Alexandria, VA 22314
while measuring a patient for crutches?
Internet address: www.apta.org
CHAPTER 23 Business and
Accounting Skills
Chapter Objectives
Observe Standard
Precautions
◆ File records using both the alphabetical and
numerical systems
◆ Utilize correct telephone techniques when
using a business telephone
◆ Schedule appointments using a standard
appointment ledger or a computer program
Caution ◆ Complete registration and history records
◆ Compose and print letters of consultation,
OBRA Requirement—Based collection, appointment, recall, and inquiry
on Federal Law
◆ Complete basic insurance forms accurately,
neatly, and thoroughly
Math Skill
◆ Maintain a bookkeeping system
◆ Write checks, deposit slips, and receipts
Science Skill
Career Information
Technology
970 CHAPTER 23
KEY TERMS
answering service deposit slips modified-block style
appointments electronic mail originator (maker)
automated routing unit enclosure notation paging system
(ARU) endorsement payee
block style (en-dors⬘-ment) pegboard system
body fax (facsimile) machine recall
buffer period filing receipt
cellular telephone heading reference initials
charge slip indexed salutation
check inquiry (in-kwy⬘-ree or in⬘- screen
collection kwih-ree⬙) signature
complimentary close inside address statement–receipt
confidential insurance forms statistical data
consultation ledger card subject line
(con-sul-tay⬘-shun) letterhead triage
cross indexes/references medical history voice mail
date line memorandums
day sheet (daily journal) (meh-mow-ran⬘-dumbz)
23:1A INFORMATION ♦ Numerical: This is the second most common

system. Materials to be filed, such as names,
Filing Records are each assigned a number. The numbers are
then placed in order and filed according to
Filing is the systematic or orderly arrangement
numerical order. This system requires a cross-
of papers, cards, or other materials so that they
index or cross-reference list. An index card file
are readily available for future reference. Correct
or computer database is usually used for this
filing methods for health care records and other
purpose. The patient’s name is placed on the
information are necessary for two main reasons.
index card or entered into the computer data-
First, it must be possible to quickly locate the
base along with the assigned number. The
material when it is needed. Second, the material
index cards or computer database is filed
must be stored safely and protected as legal
alphabetically according to last name. When a
records. Various filing systems are in use. It is
patient comes to the health care agency, his or
important that you become thoroughly familiar
her index card is pulled or the name is entered
with your agency’s method and that you follow all
into the database to determine the patient’s
instructions carefully.
number. The patient’s file is then located in
the numerical file. If patients have the same
TYPES OF FILING name, the numerical system can eliminate
errors because each patient has his or her own
SYSTEMS number. Previously, some health care agen-
cies used a person’s Social Security number
Four main filing systems are:
instead of assigning another number. How-
♦ Alphabetical: This is the most common method ever, the Health Insurance Portability and
in use. Items are filed in alphabetical order Accountability Act (HIPAA) prohibits placing
according to the same rules followed in the identifiable information such as Social Secu-
telephone directory. rity numbers on the outside of a patient’s
Business and Accounting Skills 971
chart. For this reason, random assignment of this case, a cross reference that says “See diabe-
numbers is recommended. The use of only tes” should be filed in the folder labeled Glau-
numbers on the outside of a chart also helps coma. Many agencies have special cross-reference
protect a person from identity theft if an unau- sheets that are used for this purpose.
thorized person should happen to see the
chart.
♦ Geographic: In this system, items are filed COLOR-CODED FILING
according to location. Cities, states, or coun-
tries are used as the key filing units. For exam-
SYSTEMS
ple, in a rural agency that cares for patients Color-coded indexing is an innovative method of
from several areas, charts might be filed by filing that helps prevent errors (figure 23-1A).
area or location. Within each specific area, the Each folder is marked with a series of colors rep-
charts might be filed alphabetically. A cross- resenting the letters in the patient’s name. For
reference system is usually required to prevent example, all As might be red, and all Bs might be
loss of charts. The use of geographic filing is dark blue (figure 23-1B). A series of two to eight
usually reserved for large companies or cor- colors is used to represent the letters in the
porations. patient’s last name. The colors provide a second
♦ Subject: In this system, material is filed by means of verifying placement of folders in the
subject or topic. For example, all material con-
cerning diabetes might be filed under the
topic Diabetes. A cross-reference system is
sometimes required. For example, if several
pieces of correspondence are received on an
aspect of diabetes, all the material obtained
might be filed in the diabetes folder. However,
another (alphabetical) file with the correspon-
dent’s name and a cross reference saying “see
diabetes” might be kept in case the employer
wants to refer to a specific piece of correspon-
dence.
CROSS INDEXES
OR REFERENCES
Cross indexes or references are essential in a
filing system to avoid misplacing or losing records.
Some uses of cross references were discussed in
the descriptions of filing systems. Cross refer-
ences might be kept on index cards in a separate
file, or colored sheets of paper might be placed in
file folders. For example, if a letter contains infor-
mation about three or four patients, the letter
might be filed under the topic or under the name
of the patient about whom the letter contains the
most information. A cross reference should be
placed in each of the other patients’ files. Usually
on a colored sheet of paper so that it will stand FIGURE 23-1A A color-coded filing system helps
out in the file, the cross reference would state, prevent errors because a chart with different color-
“See . . .” If a reference paper contains informa- coding will stand out if placed in an incorrect
tion about two topics, such as diabetes and glau- position. (Courtesy of Smead Manufacturing
coma, the paper might be filed under Diabetes. In Company)
972 CHAPTER 23
tor’s patients have green file folders, and a

third doctor’s patients have red file folders.
♦ Coded by type of insurance: Each type of med-
ical insurance has its own unique color of file
folder. For example, patients on Medicare
have blue file folders, patients in HMOs have
yellow file folders, and patients with private
insurance have green folders.
♦ Coded by patient name: Agencies use a differ-
ent color folder to represent the first letter of a
patient’s last name. For example, last names
starting with S are assigned a pink folder, and
last names starting with T are assigned a green
folder. This system requires 26 colors of fold-
ers, one for each letter of the alphabet.
STORAGE OF FILES
FIGURE 23-1B Color letter labels are available In a manual filing system, records are stored in
for both top- and side-cut files. (Courtesy of Smead file folders and the folders are stored in filing cab-
Manufacturing Company) inets or shelves. File folders must be durable and
of good quality. Filing cabinets or shelves must be
file. Because a chart with different color coding conveniently located, fireproof, and equipped
will stand out, a quick glance at the folders allows with locks. Sufficient file space must be available
the person filing to immediately locate a file that so that records are not packed tightly in the draw-
is out of place. ers or shelves of the filing cabinets. Because thou-
Color-coded folder systems are frequently sands of records can accumulate in a busy agency,
used in larger agencies. This system utilizes dif- most facilities have a policy to classify records as
ferent colored file folders (figure 23-1C). Some active, inactive, or closed. An active record is one
examples of color-coded folder systems include: that is currently being used because the patient is
♦ Coded by physician: A health care agency may being seen by the agency. An inactive record is a
have several doctors. Each doctor’s patients record for a patient who has not been seen for a
have a different color file folder. One doctor’s number of years, usually 2–3 years. A closed record
patients have yellow file folders, a second doc- is usually a record for a patient who has died or a
file that is no longer required.
States have different time requirements for
retention of records. For this reason, most
health care agencies keep all records in case they
are needed for legal or research purposes. Inac-
tive or closed records are frequently put on opti-
cal disks or microfiche to facilitate storage of
these records. The computer has simplified the
storage of this type of record. The record can be
copied with a laser beam and placed on an opti-
cal disk or scanned into a computer and saved on
magnetic tape or disk. The record can then be
retrieved from the optical disk or magnetic tape,
displayed on the computer, and printed in hard
copy form if it is needed. It is important to note
FIGURE 23-1C A color-coded folder system uses that the original record must be destroyed by
different colored file folders. (Courtesy of KARDEX shredding or burning to protect the confidential-
System, Inc., Marietta, OH) ity of the patient.
In an electronic filing system, agencies use particular order, check similar examples in a tele-
computers and “paperless” files. A database phone book. The main rules for this system are as
is created with the name, address, and case num- follows:
ber of the patient. The database will automati-
♦ Before names can be filed alphabetically, they
cally file all patient names in correct alphabetical
must be put into units and indexed. Dividing
order. When the patient arrives at the agency, the
a name into units simply involves separating
patient’s name is entered into the computer and
each name. For example, the name John
the database information with the case number
Robert Davis has three units: John, Robert,
appears. Some computer programs will retrieve
and Davis. The name Mary K. Kasper also has
the patient’s file by name; others require the case
three units: Mary, K., and Kasper. In the sec-
number. Once the file is retrieved, a printout can
ond example, the middle initial is considered
be obtained with pertinent information. When
to be one unit. After dividing the name into
the health care provider sees the patient, current
units, the units are indexed, or placed in
information is entered into the computerized
order for filing. The most general method of
patient file. This information can be stored in the
indexing is to place the surname (last name)
hard drive or on magnetic tape reels, disks, or
first, followed by the first name, and then the
CD-ROMs so it can be retrieved when needed. A
middle name or initial. Note the following
backup tape must be made frequently when an
examples:
electronic system is used because if the computer
(1) John Robert Davis would be indexed and
fails, or the hard drive crashes, all information
filed as Davis, John Robert.
would be lost. Most offices using an electronic
(2) Mary K. Kasper would be indexed and
system have automatic backups scheduled on an
filed as Kasper, Mary K.
hourly or daily basis to prevent losing informa-
tion. Maintaining the confidentiality of patients’ ♦ Names of organizations and businesses are
records is also essential when an electronic sys- usually filed in the same order as they are writ-
tem is used. Passwords, limited access, and locked ten. For example, American Medical Associa-
storage of disks and tapes are methods used to tion is filed with American as the first indexing
prevent access to the records by unauthorized unit, Medical as the second indexing unit, and
individuals. Association as the third indexing unit.
An efficient filing system is an important part NOTE: An exception is when the owner’s ini-
of any health care agency. Follow all instructions tials or first name form part of the name. For
carefully as you learn the system your agency example, E. J. Thomas Company would be filed
uses. Ask questions when you do not understand as Thomas, E. J., Company.
a particular procedure.
♦ Words such as of, and, at, the, on, a, and an are
STUDENT: Go to the workbook and complete not counted as indexing units. Each such word
the assignment sheet for 23:1A, Filing Records. is placed next to the word to which it belongs,
Then return and continue with section 23:1B, Fil- and in parentheses. For example, the com-
ing Records Using the Alphabetical or Numerical pany The National Company of Medical Sup-
System. plies is indexed as National (the), Company
(of ), Medical, Supplies. This would be filed
under N for National instead of T for The.
23:1B INFORMATION ♦ After a name or company is indexed, strict
alphabetical order is followed. Use as many
Filing Records Using the letters as needed. Use the telephone book, if
Alphabetical or Numerical needed, to check order. Examples are as fol-
System lows:
(1) Brooks comes before Corey, because B
ALPHABETICAL FILING comes before C.
(2) Tournovsky comes before Tournowsky.
Alphabetical filing is one of the main methods Tourno is the same in both names. The
used to file names and materials. It is the system first letter that is different is used. Because
used in the telephone book. If you question a v comes before w, Tournovsky is filed first.
974 CHAPTER 23
(3) Jones, Betty comes before Jones, Mary. Sur- (DDS). If two individuals have the same name,
names (last names) are the same, so the geographic location is used for filing. For
first letter of the first name determines the example, Jones, James Robert (MD) (Cleveland,
order for filing. The B in Betty comes before Ohio) is filed before Jones, James Robert (DDS)
the M in Mary. (Columbus, Ohio). An exception to this rule
(4) Jones, Betty C. comes before Jones, Betty F. occurs with religious or special titles followed
Here, the middle initial is used to deter- by one name. These are filed as they are writ-
mine filing position. C comes before F. ten. For example, Father John, Sister Ann, and
Prince Phillip are filed as Father, John; Prince,
♦ Nothing comes before something. For exam-
Phillip; and Sister, Ann. Titles in a firm name
ple, Brook comes before Brooks (with the addi-
are also filed as written, for example, Dr. John’s
tional letter s). Also, Brown, W. would come
Medical Supply Company.
before Brown, William.
♦ Prefixes, such as De, Del, La, Le, Mac, Mc, O, ♦ Terms of seniority such as Jr, Sr, or II are usu-
ally used as the last indexing unit. Hayden
San, St, Van, and Von, are treated as parts of
Kobelak, Jr, is indexed as Kobelak, Hayden, Jr. If
names. They are not used as separate indexing
names are identical, the seniority terms are
units. For example, in Van Dyke and O’Leary,
filed in alphabetical or numerical order. For
VanDyke is one unit, not Van and Dyke; and
example, Kobelak, Hayden, Jr, is filed before
O’Leary is one unit, not O and Leary. O’Leary
Kobelak, Hayden, Sr, and Kobelak, Hayden, II is
would be filed before Oliver.
filed before Kobelak, Hayden, III. In addition,
♦ Hyphenated names are each considered one numerical seniority terms are filed before
unit, for example, Lans-Worth, Miller-Jones, alphabetical terms. For example, Kobelak,
and Smith-Ville. Therefore, Smith-Ville would Hayden, II is filed before Kobelak, Hayden, Jr.
be filed before Smithworth.
♦ If a woman is married and uses her husband’s
♦ Familiar abbreviations are treated as though name, her name is indexed with her husband’s
the word is spelled out in full. Therefore, St. is surname as the first unit, her first name, and
filed under Saint, and Mt. is filed under Mount. then her middle or maiden name. A Mrs. is
A correct filing order is: Saccerin, St. James, often placed in parentheses at the end. The
Samson. Other abbreviations include Co. for husband’s first name is often also placed in
Company, Inc. for Incorporated, Ltd. for Lim- parentheses. So, Mrs. Kaleigh Simmers Nartker
ited, and U.S. for United States. is indexed as Nartker, Kaleigh, Simmers (Mrs.
♦ If two or more individuals have the exact same Brian).
name, the geographic location is used for fil- ♦ Numbers in a name are indexed as though the
ing purposes. In geographic order, items are number were spelled in letters. For example,
filed alphabetically first by state, then by city, 3rd Street Supply House is indexed as Third,
and finally by street address. For example, Street, Supply, House.
three individuals are named John William
Smith. One lives on Ash Street in Charleston,
West Virginia; another lives on Elm Street in
Charleston, West Virginia; and the third lives NUMERICAL FILING
on Brook Street in Charleston, South Carolina.
Correct indexing and filing order is: Smith, Numerical filing is also a common method of
John William (Charleston, South Carolina); filing. Basic principles for this system are as
Smith, John William (Ash Street, Charleston, follows:
West Virginia); and Smith, John William (Elm ♦ If a numerical system is used, cross indexing
Street, Charleston, West Virginia). or referencing is required. Patient’s names are
♦ Titles or degrees are usually not considered in usually indexed as for alphabetical filing. Each
filing but are written in parentheses at the end name is then placed on a card or in a com-
of indexed names for identification purposes. puter database, and a number is assigned.
Some common titles or degrees include MD, Numbers in an agency usually run in order,
BS, RN, DDS, and Professor. James Robert Jones, and a record is kept of which numbers have
DDS, would be indexed as Jones, James Robert been assigned. If cards are used, the card with
the name and number is kept in an alphabeti- ♦ Many systems use the same terminal, or last,
cal file. When the patient comes to the agency, digit for certain shelves or drawers. For exam-
the alphabetical card is located or the patient’s ple, a series of charts might contain 58 as the
name is entered into the computer database last digit. Another series might contain 62 as
to determine the patient’s number. The num- the last digit. Charts labeled 08-92-58, 18-99-
bered file is then located. 58, 19-34-58, and 02-41-58 are placed in one
♦ In consecutive or serial filing systems, num- group separate from charts labeled 04-45-62,
bers always go in order from small to large. 05-98-62, and 03-78-62. Then, all charts with
Number 23 is filed before number 230. By sim- the terminal digit 58 are filed in correct numer-
ply numbering from 1 on, a large number of ical order. The order for the numbers listed
patients can be accommodated. previously is 02-41-58, 08-92-58, 18-99-58, and
19-34-58. These are placed on the shelf or
♦ Many offices use nonconsecutive filing or digit-
drawer labeled 58 in the terminal system.
numbering systems in which a series of num-
Charts ending with 62 are then placed in
bers similar to Social Security numbers is used.
numerical order. The correct order for the
Numbers such as 32-444-5609 allow for a great
numbers listed previously is 03-78-62, 04-45-
variety of charts. Each office establishes a pre-
62, and 05-98-62. Therefore, in a terminal-
ferred method that should be followed.
number system, first check the last digit and
♦ If a zero falls before other numbers, the zero is then put all same last digits together. Then
usually disregarded when filing. For example, place this series in numerical order.
the number 00230 would be filed as if it were
230 and before the number 231. Most offices
use the same number of digits for each num-
ber assigned. That is why initial zeros are left STUDENT: Go to the workbook and complete
in; they are used in place of other numbers. assignment sheet number 1 for 23:1B, Filing
♦ All of the numbers listed must be checked Records Using the Alphabetical or Numerical Sys-
carefully. It is essential that numbers be writ- tem. Give the sheet to your instructor. Note any
ten clearly if this type of system is used. Most corrections or changes to the assignment sheet.
offices prefer that numbers be typed to elimi- Then complete assignment sheet number 2 to be
nate errors; otherwise, a written 1 can look sure you understand the principles outlined in
like a 7. this section. Then return and continue with the
procedure.
PROCEDURE 23:1
NOTE: If labeled file cards or folders are
Filing Records Using not available for practice, make your
the Alphabetical or own. Use 3-by-5-inch index cards (which
are less expensive than file folders). Cre-
Numerical System ate 3 sets with 40–50 cards in each set.
Make one set for alphabetical filing.
Equipment and Supplies Make sure you include examples of all
of the rules given in the preceding Infor-
Labeled file cards or folders, file drawer or
mation section. Use the telephone book
index rack
to find sample names, or make up your
own names. Make a second set of cards
Procedure for numerical filing. List a variety of
numbers on the cards. Be sure you
include examples of the principles
2. Review the Information section on filing stated in the preceding Information sec-
and refer to it as necessary throughout tion. Make a third set of cards using a
the procedure.
976 CHAPTER 23
PROCEDURE 23:1
terminal-digit numerical filing system. a. Divide the cards or folders into sets
Divide the cards into three or more according to digits. Put all two-digit
groups. Label each group with a differ- numbers (for example, 23, 68, 0023,
ent terminal digit (last number). Then 078, and 010) in one pile.
place a variety of numbers before the
NOTE: Remember to ignore any zeros
terminal digits.
before the number.
3. Assemble all of the folders or cards with
b. Place all three-digit numbers in a
names in place for alphabetical filing.
second pile. These would include
Check all names to be sure they are
numbers such as 893, 0938, 00567,
indexed correctly. Then file according to
0800, and 901.
the following steps.
c. Continue to separate the folders or
a. Separate all folders or cards into let-
cards in this manner. Create a four-
ters of the alphabet. Place all As
digit stack, a five-digit stack, and so
together, Bs together, and so forth
forth, as needed.
through the end of the alphabet.
d. Next, place all two-digit numbers in
b. Next, file just the As. Start with the
order. Start with the smallest number
second letters of all of the As and
and proceed to the largest.
place them in alphabetical order.
Proceed to the third letter, fourth let- e. Repeat step d with all remaining digit
ter, and additional letters as needed. groups. Working with smaller groups
of cards makes the process easier.
c. When the As are complete and in
order, follow the same procedure for f. Recheck the entire series of filed
all remaining letters. cards or folders. Make sure they are
in correct order by number.
d. Recheck the files. Note common
errors. Make sure you filed abbrevia- CHECKPOINT: Your instructor will
tions such as St. or Mt. as though they check the filed folders or cards for accu-
are spelled out. Make sure that you racy.
considered prefixes such as Mc or 5. Work with the terminal-number system
Van each as a part of the name and folders or cards according to the follow-
not as a separate unit. Make sure that ing steps:
you treated numbers as though they
were spelled out in letters. a. Separate the cards or folders into
groups by noting the terminal digit
CHECKPOINT: Your instructor will (last number). All cards ending with
check the filed folders or cards for accu- the same last number will be in one
racy. group, for example, 19-52, 09-98-52,
4. Work with the numerical folders or 54-19-52, and 00-01-52. Another
cards. Note only actual numbers on group might be 05-77, 09-09-77, 00-
each card. For example, 0023 would be 66-77, and 77-77.
regarded as a two-digit number, or 23; b. Working with each terminal-number
but 0300 would be regarded as a three- group, arrange each group in numer-
digit number, or 300. Ignore any zeros ical order. Ignore any zeros that come
that come before the first number. Pro- before the first number. Order num-
ceed as follows to file the numerical bers from smallest to largest. For
folders or cards: example, the series of cards ending in
PROCEDURE 23:1
52 would be filed in a group before
the series of cards ending in 77.
c. Recheck all cards or folders filed. Practice
CHECKPOINT: Your instructor will Go to the workbook and use the
check the filed folders or cards for accu- evaluation sheet for 23:1, Filing
racy. Records Using the Alphabetical or
Numerical System, to practice this
6. Repeat steps 3, 4, and 5 until you master
the systems. Read the preceding Infor-
mation section and additional refer- have mastered this skill, sign the
ences as needed. For additional practice, sheet and give it to your instructor
make up other folders or cards with for further action.
names from the telephone book or with
number systems, and file these in cor-
rect order. Final Checkpoint Using the criteria
7. Clean and replace all equipment used. listed on the evaluation sheet, your
Always answer the telephone promptly. In

23:2 INFORMATION addition, answer with a smile (figure 23-2); doing
so helps create a pleasant voice. Even though
Using the Telephone callers will not see the smile, they will be able to
BASIC TELEPHONE detect it in your voice. While talking on the phone,
keep the receiver firmly against your ear. Put the
TECHNIQUES
The telephone is an important tool of public
relations in any health agency. Because you
create an impression every time you talk on the
telephone, it is important that you use correct
techniques.
Correct use of the telephone requires many
different skills. The impression you create on the
telephone will influence a patient or other caller.
It is essential to be tactful, diplomatic, firm yet
flexible, friendly yet professional, and courteous.
You must be capable of making decisions and be
willing to accept responsibility. Developing the
correct tone of voice is essential. Your voice must
be pleasant, low pitched, clear, and distinct. A
monotone or indifferent tone should be avoided.
Words must be pronounced correctly. Correct
grammar should be used at all times. Courtesy
and good manners must be used during the entire FIGURE 23-2 Answer the telephone with a smile
conversation. Don’t forget to use the words please while holding the mouthpiece 2–3 inches away from
and thank you. your lips.
978 CHAPTER 23
mouthpiece approximately 2–3 inches away from gency calls. Triage is the process of evaluating
the center of your lips. This allows the best trans- the situation and prioritizing treatment. A list of
mission of your voice. questions is often kept by the telephone and used
Identify the office or agency—and in most to assist in evaluating the situation. For example,
cases yourself—when you answer the phone. For the following questions may be used depending
example, do not say “Hello,” “Yes,” or even just on the situation:
“Good morning,” when answering. Use greetings
such as “Good morning, Dr. Smith’s office,” “Hello, ♦ Who is the patient?
Health Care Hospital, Miss Jones speaking,” or ♦ What happened? When did it happen?
“Respiratory Clinic, Miss Jones speaking, may I ♦ Is the patient breathing? conscious? bleeding?
help you?” In this way, callers know that they have
reached the correct party.
♦ Is it possible the patient took or contacted a
poison? If so, what, when, and how much?
In many agencies, it will be your responsibil-
ity to screen calls. This means that you must ♦ Have you called emergency medical services?
determine which calls should be referred to the
By asking pertinent questions and remaining
doctor or other appropriate person and which
calm, you may be able to recognize real emergen-
calls can be handled by you or another worker in
cies. Most emergencies are referred to the appro-
the agency. Each agency usually has some policy
priate person if he or she is available. If the
regarding calls. For example, in some offices, calls
appropriate person is not available, obtain impor-
from the doctor’s immediate family (that is, wife
tant information so that you can help the caller
or husband and children) and calls from other
obtain help from the correct source. It may be
professionals are put through to the doctor. Other
necessary to refer the patient to an emergency
calls are screened to determine whether they are
medical service, emergency room, or hospital. A
emergencies or whether the caller really must
list of emergency numbers should be readily
speak with the doctor. Experience in screening
available so the correct number can be provided
calls will help you make appropriate decisions.
to the caller. Most agencies have procedures to
To screen calls, you must first obtain specific
follow when appropriate people are not available
information including:
during emergencies.
♦ Name of the caller: To determine the name of Telephone triage can also be used to deter-
the caller, you should avoid statements such mine how quickly a patient should be scheduled
as “Who is this?” or “Who are you?” It is better for an appointment. Specific questions will help
to say, “May I have your name, please?” or provide information on the seriousness of the
“May I ask who is calling, please?” If the caller patient’s condition. Questions that might be
states, “Mrs. Jones,” find out which Mrs. Jones asked include:
she is. Ask for her first name and/or her hus-
band’s name. If you are unsure of the name, ♦ What symptoms are you experiencing?
ask, “Would you please spell that?” ♦ How long have you had the symptoms?
♦ Nature or purpose of the call: When patients ♦ Do you have a fever or elevated temperature?
call a health care facility, they often simply ask ♦ Are you having any difficulty in breathing?
to talk with a particular person. By asking,
“May I help you?” or “May I tell Dr. Jones why ♦ Are you in pain? Where? How severe?
you are calling?” you can usually determine Evaluating a patient’s responses will allow
the nature of the call. At times you may have you to determine whether the patient should be
to say, “Dr. Smith is with a patient at this time, seen immediately or the patient can be sched-
may I take a message?” or “The therapist is not uled at the next convenient appointment time.
available at present, would you explain your Never hesitate to ask others for advice if you are
problem to me so I can determine if someone not certain about the seriousness of the patient’s
else can assist you?” condition.
Emergency calls must be evaluated. In some Use discretion at all times when using the
cases, a patient is upset and there is really no telephone. You should not say, “Doctor is having
emergency. Most health care agencies establish a coffee down the hall,” “He isn’t in yet, and I don’t
telephone triage procedure to deal with emer- know where he is,” “The therapist is playing golf,”
or similar comments. Statements such as, “He is

not available at present” or “I expect her to return
at four o’clock; may I take a message?” are more
appropriate.
Before ending any telephone conversation,
repeat important information to the caller. For
example, say, “Your appointment is scheduled for
10:00 A.M. on Thursday, August 8th,” or “The doc-
tor will return your call after 4 P.M. today.” At the
end of a conversation, always close with, “Thank
you for calling. Good-bye,” and replace the
receiver gently. If possible, allow the caller to hang
up first. If you hang up first, you might miss
something the patient wanted to say.
In most agencies, memorandums, or
written messages, are made of any calls that
require action. In other agencies, telephone logs
are kept, and every call is recorded. The log must
be accurate because it can be subpoenaed as a
legal record. Telephone messages should always
contain the following information (figure 23-3):
♦ Name of the caller: Note the full name. Make

sure it is spelled correctly.
♦ Telephone number of the caller: Be sure to note
the area code and extension number, if needed.
If there is a specific time when the caller can
be reached, include this information.
♦ Message: Briefly summarize the reason for the
call, but include all important information.
♦ Date and time of the call.
♦ Action required: If any action was taken, record
what was done. If action must be taken, record
the required action such as “will call back,”
“please call back,” or “please call after 3 PM.”
♦ Initials of the person taking the message: If the
message receiver has any questions, he or she
will know whom to ask.
FIGURE 23-3 A sample telephone message log
and sample telephone message form.
It is essential to keep a pencil or pen and
paper by the telephone. Most agencies use tele- Problem calls can occur in any agency. Some
phone message pads. If a copy of the message is individuals may refuse to give their names or
needed for the patient’s record or the agency’s state the purposes of their calls. At times, they
telephone log, message pads that provide a dupli- may try to intimidate or threaten the person
cate copy of each memorandum recorded can be answering the phone. Try to remain calm and to
purchased. When recording any memorandum, control your temper. Do not hesitate to say, “Dr.
always print clearly. Include all important facts Smith cannot be disturbed unless I can tell her
and spell words correctly. Using a headset with who is calling.” Be polite but firm in dealing with
the telephone frees the operator’s hands and this type of caller. If a caller gives his or her name
makes it easier to record telephone memoran- but refuses to state the general purpose of the
dums or key messages into a computer (figure call, this situation also requires tact. When in
23-4). doubt, you can put the call on hold and check
980 CHAPTER 23
number of telephone calls to be answered at the

same time. The ARU answers the telephone and a
recorded voice provides directions to the caller.
Most ARU systems provide a menu with a series
of numbers. The caller presses the correct num-
ber to connect with a specific department or
individual. The ARU system can be programmed
so a caller with an emergency can be transferred
immediately to an individual who can handle the
emergency.
Voice mail is a common feature of most ARU
systems. Voice mail is similar to the recording on
an answering machine. If the individual is not
available, the caller is instructed to leave a mes-
sage and/or directed to contact another person.
It is essential that individuals with voice mail
check messages frequently. Most telephones will
provide a signal, such as a beep, to alert the indi-
vidual that messages are on the voice mail sys-
tem. An individual who does not respond to voice
mail messages creates poor public relations.
FIGURE 23-4 Using a headset with a telephone

makes it easier to record memorandums. ANSWERING SERVICES
AND MACHINES
with the person whom the caller wants. That per- An answering service is used by many health
son can then determine whether to take the call. care agencies to respond to telephone calls when
If a call must be put on hold or you know there the agency is closed. This allows the patient to
will be a slight delay before the appropriate per- talk with an operator at the answering service
son answers the call, ask the caller, “May I put you who can transfer the call to the appropriate indi-
on hold for a moment?” Make sure the patient vidual, contact the individual and ask them to
consents to being put on hold before placing a call the patient, or record a message. The health
hold on the call. Never leave a caller on hold for care agency provides the operator with proce-
longer than 1 minute. If there is a delay, offer to dures to follow in case of emergency, telephone
take the caller’s number and have the individual numbers of individuals who may have to be con-
return the call. Be considerate of all callers. tacted, and guidelines for a variety of calls. The
Correct telephone techniques require prac- health care agency usually pays a monthly fee for
tice and experience. Think about the kind of this service.
impression you want to create; practice correct An answering machine is used in some health
responses. At all times, think before you speak. care agencies, but it is not as efficient as an
Avoid comments that might offend a caller. Treat answering service. The recording on the answer-
callers as you would want to be treated if you ing machine usually identifies the agency and
were the caller. asks the caller to leave a message. Some health
care agencies also include the hours they are
AUTOMATIC ROUTING open on the recording. If an answering machine
is used, the message on the machine should tell
TELEPHONE SYSTEMS patients what to do in case of an emergency. Most
agencies provide an alternative number a patient
Larger health care facilities frequently have tele- can call for an emergency. The answering machine
phone systems with an automated routing must be checked frequently for messages. A des-
unit (ARU). This type of system allows a large ignated individual should check for messages
immediately after the agency opens and at fre- in digital form. The e-mail message can be sent to
quent intervals if the machine is used during the another individual in place of a telephone call or
time the agency is open. letter. Insurance companies, billing services, and
health care agencies use e-mail messages to com-
municate with each other. In large health care
PAGING SYSTEMS agencies where computers are networked (elec-
tronically connected to each other), an e-mail
A paging system allows an individual to be con- message can be forwarded to many staff mem-
tacted through the use of a pager or “beeper.” The bers at the same time and take the place of a writ-
pager can provide a voice message, a signal such ten interoffice message. If an e-mail message is
as a beep that alerts the individual to call a desig- transmitted though the Internet on a modem that
nated number to receive the message, or a digital is not secure, it can be intercepted and read by
message on a display screen with the telephone others. For this reason, confidential patient infor-
number of the caller or a message. The type of mation should not be sent unless a strong encryp-
message received depends on the paging system tion program or password protection is used. In
used. Pagers are used to contact an individual. addition, patients must sign an authorization
Most do not allow for two-way communication, form before any information can be sent. There is
but they do allow access to the individual 24 no expense for e-mail on networked computers
hours a day. The individual receiving the pager in a health care agency. There is a monthly charge
message must use a telephone to contact the for Internet service that allows e-mail communi-
caller. Newer two-way pagers can be used to both cation with others.
receive and send messages, eliminating the need
for the receiver to find a telephone to respond to
the page. The health care agency usually pays a
monthly fee for each pager in use. FAX (FACSIMILE)
MACHINES
CELLULAR TELEPHONES A fax (facsimile) machine is an essential
A cellular telephone allows two-way commu- piece of equipment in many health care
nication between people in almost any location. facilities. This machine transmits data or infor-
These phones operate through cellular commu- mation electronically over the telephone lines.
nications and do not require a telephone line. For the system to work, the sending and receiving
This provides much more flexibility for an indi- facilities must each have a fax machine and a
vidual to receive calls. It is more efficient than a telephone line designated for the fax machine. To
pager, because the individual does not have to fax information to another facility, use the tele-
use another telephone to respond. A major draw- phone connected to the fax machine to dial the
back to cellular communication is that other fax number of the other facility. Place the paper
people can hear the cellular signal by using scan- containing the information to be transmitted in
ners. For this reason, confidential patient infor- the fax machine. When the fax number is answered
mation should never be discussed on a cellular at the other facility, the sending fax machine
phone. A cellular telephone is more expensive works similarly to a photocopy machine but
than a pager. In addition to a monthly charge for transmits the information electronically. When
a specific number of usage minutes, most cellu- information is being sent to a fax machine, a sig-
lar telephone service providers have an addi- nal such as a beep or light is usually given by the
tional charge for each minute of phone use over receiving fax machine. The receiving fax machine
the allotted amount. then answers the fax phone, and prints a copy of
the information being sent. Rapid transmission
of information is possible with a fax machine.
ELECTRONIC MAIL Legal and confidentiality issues must be
considered when faxing a patient’s medical
Electronic mail, or e-mail, allows an indi- records. Some newer facsimile machines are
vidual to use a computer and telephone password protected. If both the sender and
modem to send, receive, and forward messages receiver have this type of machine, a password
982 CHAPTER 23
can be used. Material will not be transmitted until ♦ Use a patient reference number instead of the
the receiver enters the password. Other ways to patient’s name when a document is sent.
meet legal and confidentiality requirements Inform the receiver about the number by tele-
include: phone or secure e-mail. Ask others to send fax
records with reference numbers instead of
♦ Always have written authorization from the names.
patient before records are faxed.
♦ Contact the receiver before faxing the material
♦ Never fax financial information. so he or she will be ready to receive it.
♦ Fax only to machines located in secure loca- ♦ Check with the receiver after the material has
tions. Never fax to machines in public areas been faxed to make sure that it was transmit-
where others might gain access to the ted correctly.
records.
♦ When in doubt, mail the records or send them
♦ Use a cover sheet that contains a confidential- by a messenger.
ity statement such as “This information is con-
fidential. Be advised that you can be prosecuted STUDENT: Go to the workbook and complete
under federal and state law for sharing this the assignment sheet for 23:2, Using the Telephone.
information with unauthorized individuals.” Then return and continue with the procedure.
PROCEDURE 23:2
6. Deal with the call or refer the call to the
Using the Telephone appropriate person, if this is indicated.
7. At the end of the conversation, thank
Equipment and Supplies the caller and say, “Good-bye.” Allow the
Telephone message pad, pen or pencil, tele- caller to hang up the phone first. Replace
phone setup the receiver gently.
8. Immediately record a memorandum of
Procedure the call. Be sure to print clearly. Record
all important facts.
1. Assemble equipment. Review the Infor-
mation section on telephone tech- NOTE: In some agencies, the message is
niques. Prepare a list of sample triage recorded during the conversation.
questions to use while answering the 9. Practice the following situations with a
telephone. Refer to these questions as partner. Assume the roles of both the
you practice obtaining information caller and the receptionist receiving the
from the caller. call.
2. Answer the telephone promptly and a. A patient calls to make an appoint-
with a smile. ment.
3. Identify yourself and the agency to the b. Another doctor calls to discuss his
caller. findings on a referred patient.
4. Determine the caller’s name and the c. A mother calls. Her child is ill.
purpose of the call. Be sure you have all
d. A salesperson calls. She has some
the facts.
new equipment she wants to dem-
5. Watch your tone of voice, manners, onstrate and discuss.
grammar, and responses during the
e. A man calls. He states that his wife
conversation.
just fell to the floor unconscious.
PROCEDURE 23:2
f. A mother calls and states that her
two-year-old child took an entire
bottle of baby aspirin.
10. Think about other situations and role-
Practice
play those situations. Use correct tele- evaluation sheet for 23:2, Using the
phone techniques. Evaluate your Telephone, to practice this
partner’s responses and let your partner procedure. When you believe you
evaluate you. Discuss different ways of
dealing with the preceding and other
situations.
for further action.
Thursday December 7
23:3 INFORMATION
8 8 8
10 10 10
20 20 20
30 30 30
40 40 40
50 50 50
9 9 9
Scheduling Appointments 10
20
30
10
20
30
10
20
30
40 40 40
One of the most frequent complaints that patients 50

10
10
50
10
10
50
10
10
voice regarding doctor’s offices, clinics, and other 20

30
40
20
30
40
20
30
40
health agencies is having to spend a lot of time 50

11
50
11
50
11
10 10 10
sitting in waiting rooms before getting to see doc- 20

30
20
30
20
30
40 40 40
tors or other appropriate health personnel. To 50
12
50
12
50
12
10 10 10
prevent this as much as possible, offices use a 20
30
20
30
20
30
carefully planned appointment book. Correct 40

50
1
40
50
1
40
50
1
scheduling of appointments is essential for 10

20
30
10
20
30
10
20
30
good public relations. 40

50
2
40
50
2
40
50
2
Appointment books or logs vary from office 10 10 10
to office (figure 23-5). However, most contain one

or one-half page for each day. Time is usually Monday February 20 Tuesday February 21 Wednesday February 22
blocked off in units of 10–15 minutes in order that 8 00

15
8 00
15
8 00
15
all time can be used wisely. Become familiar with 30

45
30
45
30
45
the type of appointment book you will use and 9 00 9 00 9 00

15 15 15
know what block of time each line represents. 30
45
30
45
30
45
An organized approach is needed to avoid 10 00 10 00 10 00
scheduling patients at times when the appropri- 15

30
45
15
30
45
15
30
45
ate person is not available. Before scheduling any 11 00 11 00 11 00

appointments, block out periods of time when 15
30
45
15
30
45
15
30
45
individuals are not available. These include time

12 00 12 00 12 00
periods for lunches, meetings, or afternoons off. 15
30
15
30
15
30
45 45 45
A large X is usually drawn through each of these
1 00 1 00 1 00
time periods so that no scheduling errors can 15 15 15
occur. FIGURE 23-5 Sample appointment books.

984 CHAPTER 23
In most agencies a pencil is used to record can again repeat the information by saying, “We
appointments. In this way, if an appointment is will expect you Friday, March 1st, at two o’clock.
canceled, names can be erased, and the time can Thank you for calling, Mrs. Clark. Good-bye.”
be assigned for another patient. Follow your If a patient schedules an appointment at the
agency’s procedure. health care facility, an appointment card should
Learn how long various procedures in your be given to the patient (figure 23-6). The card
agency take. If an examination takes 1 hour and should state the date, day, and time of the appoint-
you schedule a 15-minute appointment, you will ment.
be 45 minutes behind for later appointments. After scheduling an appointment, make sure
Many agencies keep lists of standard procedures you mark the full amount of time in the book. In
and average time required for each near the many agencies, arrows that extend down from
appointment book. the patient’s name to fill in the entire time block
Appointments should be scheduled as close the patient will require are used. This also pre-
together as possible, but not so close that patients vents scheduling errors.
will feel rushed in the office or be required to wait If a patient calls to cancel an appointment, be
for long periods. Long periods of unscheduled polite. Ask the patient if he or she would like to
time are wasteful and cost money. Some agencies reschedule the appointment. Erase the appoint-
schedule a 15- to 30-minute buffer period in ment or remove it from the book by drawing a
the middle of each morning and afternoon. This single line through the entry. Then record all new
allows time to catch up if some appointments information in the correct time block. It is not
run over. If the appointments run as scheduled, necessary to pry and ask patients why they must
this time can be used for other business such as cancel. Many patients will offer explanations; if
returning telephone calls or seeing patients with they do not, however, do not question them.
emergencies. Chronic scheduling problems occur in every
When a patient calls for an appointment, agency. Some patients schedule appointments
find out the reason for the appointment. and then do not show up for them. If a patient
Then try to accommodate the patient by sched- becomes a chronic offender, there are several
uling an appointment convenient for him or her. methods of dealing with the problem. One
Questions such as, “Do you prefer morning or method is to schedule the patient at the end of
afternoon?” “Which day is most convenient?” the day. This way, if the patient does not keep the
and “Would two o’clock or four o’clock be more appointment, other patients and the schedule
convenient?” give the patient a choice and help will be minimally affected. In some agencies, bills
you select the correct time and day. Sometimes, for time scheduled are sent to patients who do
choices are limited because the appointment not keep appointments. In these agencies,
book is full. However, by giving patients as much patients must be told that if they cannot keep
choice as possible, you let them know that you
are trying to accommodate them.
Make sure you have the required informa-
tion before closing your conversation with
the patient. Obtain the full name of the patient.
Do not hesitate to ask the patient to spell the
name if you are not sure of the correct spelling.
Determine the reason for the appointment. It is
also wise to get the patient’s telephone number in
case an emergency requires cancellation of the
appointment. Writing the telephone number in
the appointment ledger eliminates having to find
the number in the patient’s record and saves time.
Repeat the date, day, and exact time of the
appointment to the patient. By giving both date
and day, you provide a double check and prevent FIGURE 23-6 Appointment cards containing the
errors. Make sure the patient understands all date, day, and time of an appointment should be
information. Before hanging up the phone, you given to the patient.
appointments, they must notify the office 24 appointments are behind schedule, offer the
hours in advance or they will be charged for the patient a choice between waiting or scheduling
time scheduled. In most agencies, canceled another appointment. If told that an emergency
appointments or “no-shows” are noted on has occurred (the full nature of the emergency
patients’ charts. If the individual who canceled or need not be explained) and they will have to wait,
didn’t appear for an appointment needs continu- many patients will be willing to do so. However,
ing care, efforts must be made to contact the per- patients should never be left waiting without an
son. For example, suppose an individual had explanation.
surgery and sutures must be removed; if the In many health care agencies, appointment
sutures are not removed, an infection could scheduling is done by computer. The com-
develop and the individual could initiate legal puter automatically locates the next available
action claiming negligence. Most agencies have a date and time, provides a record of appointments
policy that requires calling the patient and record- already scheduled, can be programmed to sched-
ing the date and time of each call on the patient’s ule a set block of time for a particular procedure,
chart. If there is no response from the patient and prints out copies of the daily schedule.
after several telephone calls, a letter is sent to the Although computerized scheduling can be effi-
patient explaining the need for care. Document- cient and convenient, an alternate system must
ing all efforts in the patient’s chart provides legal exist for downtime, or times when the computer
protection if the patient files a lawsuit. The final is not functioning.
decision on how to deal with these situations Correctly scheduling appointments takes
rests with the individual in charge. Be sure you practice. If your present system is resulting in
know and follow his or her policy. long waits for patients, review your system. Deter-
Emergencies occur in every agency. In the mine whether longer time periods are necessary
case of an emergency, appointments may run for each patient. Add additional buffer times for
later than scheduled. Sometimes, it is necessary overlap or emergency patients, if indicated. Con-
to cancel all appointments scheduled. If possible, stantly be willing to try to correct problems and
patients should be notified by telephone before create a good impression of the agency.
they come to the office or agency. When you call
to cancel an appointment, make every effort to STUDENT: Study the procedure for 23:3,
reschedule the patient at a time convenient to Scheduling Appointments, before completing any
him or her. If a patient arrives at the office and assignment sheets.
PROCEDURE 23:3
Scheduling Procedure
Appointments 1. Assemble equipment. Check the ap-
pointment book ledger or worksheet.
Equipment and Supplies Note how much time each line repre-
sents. Examine the sample appointment
Appointment book ledger or worksheet, pen- schedule in figure 23-7.
cil, assignment sheets numbers 1 and 2, 23:3, NOTE: Appointment books vary. Many
Scheduling Appointments. contain lines that each represent a 15-
NOTE: If you are using a computer pro- minute period. In these books, the line
gram to schedule appointments, follow labeled 9:00 represents the time from
the instructions provided with the soft- 9:00 to 9:15.
ware. The same principles will apply, 2. Place the day and date on the top of
but the computer will identify available each of the daily columns. This provides
appointment times and allocate the cor- a double check.
rect amount of time based on the proce- 3. Block off those periods of time when the
dure entered. person for whom appointments are
986 CHAPTER 23
PROCEDURE 23:3
MONDAY FEB. 8, 20--
c. The reason for the appointment is
DAY DATE
briefly listed. Abbreviations can be
(CONFERENCE–DEPARTMENT
9:00 used.
HEADS)
9:15 d. The telephone number of the patient
WENDALL H. SMOKER–CHEST X-RAY–555-4328 is noted. Check to be sure the num-
9:30
ber is correct.
9:45 JANE R. THINNER – DIET CHECK – 555–3811
e. The entry is printed and easy to read.
10:00 SUSAN MOCKS (MRS. FRANK) – 555–3428
6. Double-check each entry. Some time
10:15 TOENAIL SURGERY periods may have to vary slightly.
10:30 (BUFFER) 7. Turn in assignment sheet number 1 or
print a copy of a computer-generated
10:45 JOE J. ATHLETIC – PHYS. EX. – 555–5318
schedule to be graded. Your instructor
11:00 will correct it and note changes to be
11:15
made.
SIMMERS CHILDREN: SHARON, KAREN, JOE
11:30
grade assignment sheet number 1
(MR. FLOYD W .) IMMUNIZATIONS – 555–2897
11:45 according to the criteria listed on the
12:00 (LUNCH) evaluation sheet.
8. When assignment sheet number 1 has
12:15
been graded, note all changes and cor-
FIGURE 23-7 A sample appointment rections. If you do not understand a
schedule. change, be sure to ask your instructor
being scheduled will not be in. Put a for help before doing assignment sheet
large X through each of these time peri- number 2.
ods. If the reason is known, write a brief 9. Complete assignment sheet number 2
explanation such as medical meeting to for 23:3, Scheduling Appointments, in
block out the time period. your workbook. Follow steps 1–6. When
4. If your agency requires a buffer time, you have checked all entries, turn the
mark this time period. It can be used for sheet in or print a computer-generated
emergency patients or catch-up time. schedule to be graded.
5. Begin working with assignment sheet 1, 10. Replace all equipment.
23:3 Scheduling Appointments, in your
workbook. Read each case listed. Note
the time required and time preferred.
Using a worksheet, schedule each of the Practice
cases. Check each case and notation to Go to the workbook and use the
be sure of the following: evaluation sheet for 23:3,
a. Full name of the patient is listed and, if Scheduling Appointments, to
a female is married and uses her hus- practice this procedure and to
band’s name, the spouse’s name is in complete the two assignment sheets
parentheses. Spelling must be correct. for 23:3, Scheduling Appointments.
b. The patient is in the correct time slot.
Draw arrows downward from the
name to indicate the time needed. Final Checkpoint Using the criteria
Draw only to the end of the patient’s listed on the evaluation sheet, your
appointment. instructor will grade your performance.
diagnosis. These forms also vary but most forms

23:4 INFORMATION contain the following basic parts (figure 23-10):
Completing Medical Records ♦ General statistical data: These data include
and Forms name, address, age, and other similar infor-
mation.
Medical records vary but some forms are
used for certain purposes. Two common ♦ Family history: Family history includes infor-
forms are statistical data sheets or cards and mation on members of the patient’s immedi-
medical history records. All records are consid- ate family, including parents, grandparents,
ered to be confidential. No information can be sisters, and brothers. Questions are asked
released from the records without the written regarding heart disease, cancer, mental disor-
consent of the patient. These forms belong to the ders, diabetes, epilepsy, kidney disease, and
physician or agency. They should be locked up allergies. If a family member has died, the
when not in use. cause of death and age at time of death are
Statistical data sheets are also called regis- recorded. Only information regarding blood
tration forms or patient information forms (figure relatives is obtained. Information regarding
23-8). This form is usually completed on a relatives by marriage, such as a mother-in-
patient’s first visit to an office or health agency. law, is not obtained because the patient can-
On subsequent visits, patients are asked to verify not inherit diseases from these individuals.
the information to be sure it is correct. The statis- ♦ Patient’s medical history: Medical history
tical data sheet contains basic reference informa- includes past illnesses, treatments, opera-
tion about the patient. The form may be a sheet tions, accidents, physical defects, allergies,
of paper, an index card, or even the inside of the childhood diseases, and other similar items.
patient’s folder. In many offices, the information For each past illness, the year of the illness or
is entered into a computer database. A sample the patient’s age at the time of the illness is
entry screen is shown in figure 23-9. No matter recorded. For each past operation, the date of
what type of form is used, most contain the fol- the operation or the age of the patient at the
lowing information: time of the operation and the type of opera-
♦ Patient’s name in full tion are recorded.
♦ Patient’s address, including city and zip code ♦ Personal/social history: This may include ques-
tions about the patient’s diet, sleep, or exercise
♦ Patient’s telephone number
routines and personal habits such as smoking
♦ Patient’s marital status, sex, and birthdate or alcohol use. In the case of a female patient,
♦ Patient’s place of employment information regarding pregnancies, number
of children, abortions, and menstrual pattern
♦ Name of the person responsible for the is also recorded.
account
♦ Present illness or ailment: This is an exact
♦ Insurance company information including description of the signs and symptoms the
address, policy and group numbers, and other patient is currently experiencing. Information
pertinent information about when the illness first occurred, any pre-
♦ Name of referring physician or other person vious treatment, and other pertinent informa-
tion offered by the patient should be noted.
In most agencies this information is typed on
This section is sometimes designated as chief
the form or keyed into a computer database. If a
complaint.
computer is used, a printed copy may be placed
in the patient’s record. Care must be taken to ♦ Physical examination or Review of Systems
ensure that all information is accurate. Double- (ROS): The physician performs an examina-
check numbers and spelling. tion of all body systems and records both
A medical history record is another impor- positive and negative findings. This section
tant form used in almost all health care agencies. may also include results from laboratory tests,
Information on this form helps the practitioner although there is sometimes a separate sec-
provide better care and, at times, even make a tion for laboratory tests.
988 CHAPTER 23
PATIENT INFORMATION DATE:

PATIENT'S NAME MARITAL STATUS DATE OF BIRTH SOCIAL SECURITY NO.
S M W DIV SEP
STREET ADDRESS PERMANENT TEMPORARY CITY AND STATE ZIP CODE HOME PHONE NO.
PATIENT’S EMPLOYER OCCUPATION (INDICATE IF STUDENT) HOW LONG BUSINESS PHONE NO.
EMPLOYED?
EMPLOYER’S STREET ADDRESS CITY AND STATE ZIP CODE
IN CASE OF EMERGENCY CONTACT: DRIVERS LIC. NO.
SPOUSE’S NAME
SPOUSE’S EMPLOYER OCCUPATION (INDICATE IF STUDENT) HOW LONG BUSINESS PHONE NO.
EMPLOYED?
WHO REFERRED YOU TO THIS PRACTICE?
IF THE PATIENT IS A MINOR OR STUDENT

MOTHER’S NAME STREET ADDRESS, CITY, STATE AND ZIP CODE HOME PHONE NO.
MOTHER’S EMPLOYER OCCUPATION HOW LONG BUSINESS PHONE NO.

EMPLOYED?
FATHER’S NAME STREET ADDRESS, CITY, STATE AND ZIP CODE HOME PHONE NO.
FATHER’S EMPLOYER OCCUPATION HOW LONG BUSINESS PHONE NO.

EMPLOYED?
INSURANCE INFORMATION
PERSON RESPONSIBLE FOR PAYMENT, IF NOT ABOVE STREET ADDRESS, CITY, STATE AND ZIP CODE HOME PHONE NO.
COMPANY NAME & ADDRESS NAME OF POLICYHOLDER CERTIFICATE NO. GROUP NO.
COMPANY NAME & ADDRESS NAME OF POLICYHOLDER POLICY NO.
COMPANY NAME & ADDRESS NAME OF POLICYHOLDER POLICY NO.
MEDICARE MEDICARE NO. MEDICAID PROGRAM NO. COUNTY NO. ACCOUNT NO.
In order to control our cost of billing, we request that office visits be paid at the time service is rendered. We would rather control our
billing costs than be forced to raise our fees.
AUTHORIZATION: I hereby authorize the physician indicated above to furnish information to insurance carriers concerning this
illness/accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially
responsible for all charges whether or not covered by insurance.
Responsible Party Signature
FIGURE 23-8 A sample statistical data sheet or patient information form.

important that the patient feels relaxed and at

ease during the questioning. Note any additional
information that the patient provides if it seems
important to the overall history. If no specific
areas are provided on the forms for this type of
information, be sure the physician or other
appropriate person is made aware of the infor-
mation.
Legal requirements must be observed while
working with medical records. It is essential
to remember that all information on the record is
confidential and cannot be given to any other
individual, agency, or insurance company with-
out the written permission of the patient. HIPAA
FIGURE 23-9 Statistical data about the patient requires that records must be stored in a secure,
can be entered into a computer database by using a locked area with limited access. Computerized
patient entry screen. records must use encryption technology and/or
password protection. All records must be main-
tained for the period of time required by law. If an
♦ Diagnosis, prognosis, treatment rendered: error is made while recording a paper medical
These sections can be separate or combined
record, the error should be crossed out in red ink,
on the form. They are completed by the physi-
dated, and initialed. Correct information is then
cian after all of the previous information is
recorded and noted as Corr or Correction. Incor-
reviewed. The diagnosis is the physician’s
rect data on a computerized medical record must
judgment regarding what disease or condition
never be deleted or keyed over. Using the tracking
the patient has. Sometimes a tentative diag-
device on word-processing software programs,
nosis is listed, or the physician may write
the error should be lined out or highlighted and
“R/O” followed by the name of one or more
marked as an error. The correct information
diseases to indicate that tests should be done
should then be inserted, together with the date
to rule out the diseases listed. The prognosis is
and initials or name of the person making the
the physician’s opinion regarding the course
correction.
and expected outcome of the disease or con-
An awareness of cultural diversity is essential
dition, such as “terminal in 3–6 months” or
when information is obtained. In some cultures,
“full recovery in 1–2 weeks.” Any specific treat-
individuals feel it is disrespectful to speak of the
ment given is also listed.
dead. A patient may hesitate to discuss family
In most agencies, the health care worker will history and illness if the person is deceased. A
complete only the statistical data informa- similar situation may exist in cases of adoption
tion and/or family history, patient’s medical his- where biological family history is not known. An
tory, and personal history sections. The physician interpreter may be needed if a patient has limited
or another authorized person will do all other English and speaks a foreign language. Patients
parts of the medical history. may refuse to discuss family problems that may
The patient must have privacy when being be causing stress and/or physical problems if
questioned. A separate room should be they believe that this is personal information. If
used, and the door to the room should be closed. an individual has a cultural belief that illness is
Specific questions must be asked. It is essential caused as a punishment for sin, the patient may
that questions be asked in a professional rather not want to discuss specific symptoms or prob-
than prying manner. It is also important to make lems. In some cultures, individuals do not discuss
sure the patient understands the meaning of all pain. These individuals believe pain is something
questions. For example, diabetes may have to be that must be tolerated and accepted; acknowl-
explained as “sugar.” Information obtained must edging pain is a sign of weakness. Many individu-
be accurate and complete. Facts should be als may be hesitant to discuss cultural or religious
rechecked as necessary. The patient should be remedies they have tried, such as herbal reme-
given time to think about each question. It is dies, acupuncture, witchcraft, or religious rituals.
990 CHAPTER 23
FIGURE 23-10 A sample medical history form.

The health care worker must show respect, toler- ♦ W for widowed
ance, and acceptance of a patient’s cultural and
religious beliefs while obtaining information for
♦ D for divorced
the medical record. ♦ O for negative or none
The final version of the medical history record ♦ l and w for living and well
is usually typed, or keyed into a computer pro-
♦ d for died (year of death is usually placed after
gram and printed for the patient’s permanent
the symbol)
record. Make sure any handwritten copy is legible
and clear. Double-check all information to make ♦ NA or N/A for not applicable, or does not
sure it has been recorded correctly. apply
Some common abbreviations used on medi-
cal records and forms are as follows: STUDENT: Go to the workbook and complete
the assignment sheet for 23:4, Completing Medical
♦ S for single Records and Forms. Then return and continue
♦ M for married with the procedure.
PROCEDURE 23:4
2. Complete the statistical data sheet. Ask
Completing Medical questions in a polite manner. Speak
Records and Forms clearly and distinctly. Observe all of the
following points:
NOTE: A blank statistical data sheet and
a. Type or print the name clearly. Check
blank medical history sheet are in the
spelling.
workbook. Use these sheets to practice
this procedure. You may also use other b. Fill in the complete address of the
varieties of the sheets and adapt the patient’s permanent residence. Use
questions to the information required. the space provided.
c. List the full telephone number of the
Equipment and Supplies patient’s residence. If the patient
Statistical data sheet, medical history sheet, does not have a telephone, put
pen or typewriter “none.” Do not leave blank because
doing so indicates that you have
NOTE: If a computer program is used to omitted the question. If the phone
complete medical records, follow the number is not local, list the area
instructions provided with the software. code.
Basic principles provided in this proce-
dure are still followed when information d. Fill in the personal information
is entered into the computer. requested, including age, full birth-
date (month, day, and year), and sex.
Procedure e. Circle either S, M, W, or D to indicate
the patient’s marital status. The let-
1. Assemble equipment. Use a private area ters stand for single, married, wid-
for questioning the patient (lab partner owed, or divorced.
in a practice situation).
f. List the patient’s full Social Security
NOTE: A separate room with the door number, placing dashes (-) between
closed is preferred. sections of the number (for example,
CAUTION: Patient information is confi- 218-00-0100).
dential. The patient’s legal right to pri- CAUTION: Repeat and check numbers
vacy must be observed. for accuracy.
992 CHAPTER 23
PROCEDURE 23:4
g. List the spouse’s name (the name of mation. If an incorrect entry is noted on
the patient’s husband or wife), if this a computer page, use the tracking pro-
is requested. If the patient is single, gram of the word-processing software
widowed, or divorced, put “NA” for to line out or highlight the incorrect
“not applicable.” information. Mark it as an error and
then insert the correct information
h. List the patient’s place of employ-
together with the date and initials or
ment. Include address, telephone
name of the person making the correc-
number, and other information
tion.
requested. If the patient is not
employed, put “none” or current 4. Complete the medical history form. Ask
work status such as “student,” each question clearly. Obtain all perti-
“homemaker,” or “retired.” nent information such as dates of ill-
nesses, treatments for illnesses, and
i. List the full name of the person
details of complaint. Be professional.
responsible for the account. If this is
Allow the patient time to think about
the patient, list “self.” If it is a hus-
the answers. Be sure the patient under-
band, wife, or parent, complete all
stands all questions. Describe the vari-
requested information.
ous symptoms as stated. Make sure the
j. List the full name of the insurance patient has privacy when answering the
company and the company’s address questions. Note the following points:
and telephone number. Double-
a. Complete all parts of the form. If
check the policy number to be sure it
answers are “no” or “none,” the sym-
is accurate. This information is essen-
bol O is sometimes used. Some ques-
tial for billing.
tions may not apply to the patient.
NOTE: Be sure to include dashes, letters, An example would be menstrual his-
and other parts of the policy number. tory, which would not apply to a male
NOTE: Most agencies make a copy of patient. Use NA for “not applicable.”
both the front and back of the patient’s b. Complete the first part using infor-
insurance card to place in the patient’s mation from the statistical data sheet
file. previously completed. If no data
k. In the referred by section, place the sheet was completed, fill in as
name of the person who suggested instructed.
your agency to the patient. This could c. Under family history, record informa-
be another physician, another tion on blood relatives only. Do not
patient, a friend, a relative, or even include information on the patient’s
the telephone directory. in-laws. Symbols can be used, such as
3. Recheck the information on the statisti- l and w for “living and well”; d. in 1960
cal data sheet as needed. Be sure all indicates the family member died in
information is printed, typed, or keyed 1960. Under sisters and brothers, list
into a computer correctly. If an error number of each. If any have died, list
occurs on a printed paper copy, draw a the date and cause of death. Explain
single red line through any incorrect the diseases listed and question the
entry and put your initials and the date patient about any relatives who have
near the line. Then insert the correct or had the disease.
information together with Corr or Cor- d. Under past medical history, record
rection to indicate it is the right infor- any illnesses the patient has had. List
PROCEDURE 23:4
the date of the illness or the age of mation together with Corr or Correction
the patient at the time of the illness. to indicate it is the right information. If
The symbol O can be used if the an incorrect entry is noted on a com-
patient has not had the disease. List puter page, use the tracking program of
types of operations and dates. the word-processing software to line out
or highlight the incorrect information.
e. Under personal history, obtain all
Mark it as an error and then insert the
pertinent information. Be specific.
correct information together with the
For example, do not just put “yes” for
date and initials or name of the person
tobacco use; put “two packs per
making the correction. A copy of a com-
day.”
puter-generated medical history is usu-
f. List the present ailment or chief com- ally printed and placed in the patient’s
plaint in detail. For example, enter file.
“continuous sharp pain in upper
6. Prepare the patient for the physical
right arm” instead of “pain in arm.”
examination, if indicated. (This proce-
List any previous treatment, includ-
dure was explained in Information sec-
ing treatments the patient has tried
tion 20:4.)
by himself or herself. List the date of
onset (when the problem started). 7. Replace all equipment.
NOTE: In many agencies, the physician
or other authorized person completes
the medical history. Make sure that the
patient and physician or other autho-
rized person have privacy during this
Practice
time. Have forms, a pen, and/or a com- evaluation sheet for 23:4,
puter readily available. Completing Medical Records and
5. Recheck the medical history record to Forms, to practice this procedure.
be sure all parts are complete. Note any When you believe you have
additional information provided by the mastered this skill, sign the sheet
patient. Make sure numbers, dates, and give it to your instructor for
spelling, and other information are further action.
accurate. If an error is present on a paper
copy of the medical history, draw a sin-
gle red line through the incorrect entry Final Checkpoint Using the criteria
and put your initials and the date near listed on the evaluation sheet, your
the line. Then insert the correct infor- instructor will grade your performance.
23:5 INFORMATION ♦ Collection letter: Encourages a patient to

pay an account that is due. Collection letters
Composing Business Letters frequently are sent to patients who do not
TYPES OF LETTERS respond to bill statements.
♦ Appointment letter: Informs a patient of a
There are many different types of business scheduled appointment. All information
letters. Some types of business letters you including the day, date, and time must be
may be required to prepare include: included in the letter.
994 CHAPTER 23
♦ Recall letter: Reminds a patient that it is time ten. The second paragraph lists the main facts.
to return for a periodic examination. A The third paragraph is the sign off or final
reminder letter for a 6-month dental check-up reminder.
is one example. In some agencies, recall cards ♦ Complimentary close: This is a courtesy,
are sent to patients. most commonly Sincerely, Sincerely yours,
♦ Consultation letter: Sent to another profes- Respectfully yours, or Yours truly. Only the first
sional to request an examination of a particu- word of the complimentary close is capital-
lar patient. It is sometimes used as a referral to ized.
another physician, therapist, or treatment/ ♦ Signature: The signature is the name and/or
diagnostic agency. title of the person writing the letter. Leave
♦ Inquiry letter: Seeks some information. A let- space after the complimentary close for a
ter asking a patient for information about handwritten signature, and then key the name
medical insurance is one example. and title of the person who is sending the
letter.
♦ Reference initials: Reference initials are the
PARTS OF A LETTER initials of the person dictating the letter and
the initials of the person preparing the letter,
Every letter must include certain parts. The parts or the initials of just the preparer.
and their components are as follows: ♦ Enclosure notation: If enclosures are
♦ Letterhead or heading: In most cases, included with the letter, this is noted at the
printed stationery is used. The agency’s name, end of the letter with a brief description of the
address, and telephone number are printed material enclosed.
on the paper as a letterhead. Some health care
agencies also include their fax number, Inter-
net address, and/or e-mail address. If there is
no printed letterhead, a heading is keyed on
PROPER FORM
the paper. The heading includes the address FOR LETTERS
of the individual sending the letter, including
When keying a letter into a computer, it is impor-
the city, state, and zip code, and the date of
tant to follow specific rules and use correct spac-
writing.
ing. Some of the main points to observe are as
♦ Date line: The date the letter is being written follows:
is keyed (typed) under the letterhead.
♦ All letters must be neat and professional.
♦ Inside address: This is the name, address, Spelling and punctuation must be correct. Use
city, state, and zip code of the person or firm the spelling and grammar checks on the com-
to whom the letter is being sent. puter to correct errors. Use a dictionary to
♦ Salutation: This is the name of the person to check medical or dental terms that might not
whom the letter is directed. The salutation be on the computer spell-checker.
should include the title such as Dear Mr, Mrs, ♦ The style for letters varies. Follow the style
Ms, or Dr followed by the last name of the per- desired by your agency. Two common styles
son. If the letter is addressed to a company, are block style and modified-block style. In
the salutation should read Gentlemen. If the block style (figure 23-11), all parts of the let-
letter is addressed to a title (for example, ter are aligned starting at the left margin of
human resources manager), the salutation the paper. In modified-block style (figure
should read Dear Sir or Madam. 23-12), certain parts of the letter are aligned at
♦ Subject line: Some letters may include a the center line of the paper and the remaining
subject line to reference the reason for writ- parts are aligned at the left margin of the paper.
ing. This is not present in all letters. ♦ If a letterhead is printed on the paper, space
♦ Body: This is the message of the letter. Most down approximately 15 lines from the top of
letters include three paragraphs. The first the document or three to four lines below the
paragraph states why the letter is being writ- letterhead. Begin keying at the center line for
FIGURE 23-11 The form for a block-style letter. All sections are aligned at the left margin.
modified-block style or at the left margin for On the next line (again starting at the center
block style. Key in the month, day, and year. line or left margin, depending on style) key the
Do not abbreviate the month. full name of the city, the state (full name or
♦ If preprinted letterhead is not used, key a correct abbreviation), and zip code. Leave one
heading on the paper. Start 1–2 inches (9–12 space after the name of the state before keying
blank lines) from the top of the paper. Begin- the zip code. The third line of the heading
ning at the center line for modified-block style includes the full name of the month, the day,
or at the left margin for block style, key the and the year.
street number and name. Do not abbreviate ♦ Space down five lines and begin the inside
words such as Road, Avenue, Street, and Lane. address on the fifth line below the last line of
996 CHAPTER 23
LEWIS & KING, MD Northborough
L&K 2501 Center Street

Northborough, Oh 12345
Fa m i ly M e d ic a l G r o u p
January 12, 20 ——— (approximately 15th line)
Jeremy Brown, MD (approximately 20th line)

111 S Main
Blossom, UT 10283-1120
Dear Dr. Brown:
Blossom Medical Society Meeting
Thank you for inviting me to speak at the Blossom Medical Society

Meeting June 15, 20 ———. As requested, my topic will describe the use of
the MRI in assisting physicians to make a more accurate diagnosis with-
out resorting to invasive procedures. The exact title of my speech will
be sent by next Friday.
Please have your office manager send information regarding the number of
participants expected, time of meeting, location, and any other details
that will assist me in preparing my speech.
I will write or call if I have any additional questions.
Yours truly,
Winston Lewis, MD
Winston Lewis, MD
WL:jg
Enclosure: Handout on MRI
FIGURE 23-12 The form for a modified-block style letter.
the heading. Start at the left margin line is the city, state, and zip code. Leave one space
regardless of style. The inside address should but no punctuation after the name of the state
be at least three lines long. The first line is the before keying the zip code.
name and title (for example, Mr. or Miss) of the
person to whom the letter is being sent. Never ♦ Space down two lines (double-space) and
use a double title such as Dr. D.A. Jones, M.D.; begin the salutation on the second line below
rather, use D.A. Jones, M.D. The second line is the inside address. A colon (:) should follow
the street number and address. The third line the salutation. Start on the left margin regard-
less of style. Capitalize all words in the saluta-

tion, for example, Dear Mr. Brown:, Dear Dr. SUMMARY
Jones:, or Dear Madam:.
At times, using the full name of a state or territory
♦ If a subject line is included in the letter, space makes a letter seem unbalanced. In such cases,
down two lines (double-space) below the sal- the name of the state or territory is abbreviated.
utation. Begin keying at the left margin to Only the abbreviations shown in figure 23-13 are
insert the subject of the letter. acceptable. They are recommended by the U.S.
♦ Space down two lines and begin keying the Postal Service. Note that both letters are capital-
body on the second line after the salutation or ized and that no periods are used in the abbrevia-
subject line. Single-space within paragraphs; tions.
double-space to separate paragraphs. Start All letters should be proofread before the
each line of the body on the left margin. In sender receives them for signature. Make sure
most cases, the first line of any paragraph in that all words are spelled correctly and that com-
either modified-block style or block style is plete sentences and correct punctuation are
not indented. Some agencies, however, may used. Use the spelling and grammar checks avail-
indent the first line of each paragraph five able on most word-processing programs. In most
spaces in a modified-block style letter. Follow agencies, computers and word processing soft-
agency policy. ware are used to prepare letters, so it is easy to
correct errors on the computer screen prior to
♦ Space down two lines after the last sentence in
the body and begin keying the close. Start at
AL Alabama NE Nebraska
the center line for modified-block style or at
AK Alaska NV Nevada
the left margin for block style. Capitalize only
AS American Samoa NH New Hampshire
the first word of the complimentary close and
AZ Arizona NJ New Jersey
place a comma at the end of the close, for
AR Arkansas NM New Mexico
example, Sincerely, Sincerely yours, Respect-
CA California NY New York
fully yours, or Yours truly.
CO Colorado NC North Carolina
♦ Leave four to five blank lines for the written CT Connecticut ND North Dakota
signature and begin the keyed name and title DE Delaware MP North Mariana
on the fifth or sixth line below the complimen- DC District of Islands
tary close. Start at the center line for modified- Columbia OH Ohio
block style or at the left margin for block style. FL Florida OK Oklahoma
Key the name and title of the person sending GA Georgia OR Oregon
the letter. Long titles may be placed on a sec- GU Guam PA Pennsylvania
ond line under the name. HI Hawaii PR Puerto Rico
♦ Double-space after the keyed name and title, ID Idaho RI Rhode Island
and key the reference initials. Start at the left IL Illinois SC South Carolina
margin regardless of style. Key either the ini- IN Indiana SD South Dakota
tials of just the preparer or the initials of the IA Iowa TN Tennessee
writer and the initials of the preparer. Use either KS Kansas TX Texas
capital or small letters. If two sets of initials are KY Kentucky TT Trust Territory
used, use a colon to separate capitalized initials LA Louisiana UT Utah
and a slash to separate lowercased initials, for ME Maine VT Vermont
example, LMS:WHB or lms/whb. Some agen- MD Maryland VI Virgin Islands,
cies use capital initials for the writer, lowercase MA Massachusetts U.S.
initials for the preparer, and a colon to separate MI Michigan VA Virginia
the two sets of initials. Follow agency policy. MN Minnesota WA Washington
MS Mississippi WV West Virginia
♦ Leave neat, even margins at both sides of the
MO Missouri WI Wisconsin
paper. Margins should be wide enough to be
MT Montana WY Wyoming
attractive, but not too wide as to distort. An
average width for margins is 1–11⁄2 inches. Leave FIGURE 23-13 U.S. Postal Service abbreviations
a bottom margin of at least 1 inch (six lines). for states and territories.
998 CHAPTER 23
printing a hard copy of a letter. In addition, most large number of personalized letters. Computer
health care agencies have standard form letters classes can help the health care assistant learn
saved in a computer database. When a letter is how to utilize the many features present in word-
needed for a specific purpose, such as a letter of processing programs.
appointment, the letter of appointment form let-
ter is retrieved. The patient’s name and personal
information are keyed into the form letter. If the STUDENT: Go to the workbook and complete
same letter has to be sent to a large group of peo- the assignment sheet for 23:5, Composing Business
ple, the mail merge feature (found on most word- Letters. Then return and continue with the proce-
processing programs) can be used to create a dure.
PROCEDURE 23:5
NOTE: Margins should be wide enough
Composing Business to appear attractive, but not so wide as
Letters to distort. The average width is 1–11⁄2
inches.
NOTE: You must have computer, word
processing, and keyboarding skills to 5. If a letterhead is preprinted on the paper,
complete this procedure. space down to the 15th line and key in
the month, day, and year. Begin at the
Equipment and Supplies center line for MB or at the left margin
for B.
Computer with word-processing software
NOTE: Most health care agencies use
and printer (or typewriter), letterhead or good
paper with a letterhead. If no letterhead
quality paper, scrap paper, pen or pencil
is present, space down approximately
15 lines from the top of the document.
Procedure Key the heading (sender’s address and
date) starting at the center line for MB
1. Read the preceding Information sec-
or at the left margin for B.
tion, Composing Business Letters.
6. Space down five lines. On the fifth line,
2. Determine a topic for a business letter
key the inside address, starting at the
or obtain a topic from your instructor.
left margin.
Decide on the style of the letter (that is,
modified-block or block). Your instruc- 7. Space down two lines (double-space).
tor may specify a style. Key the salutation, starting at the left
margin. Insert a colon (:) after the salu-
NOTE: In the following steps, MB indi-
tation.
cates modified-block style, and B indi-
cates block style. 8. If a subject line is included in the letter,
space down two lines, begin at the left
3. Use scrap paper to write a rough draft of
margin, and key in the subject of the let-
the letter. Check to be sure all required
ter.
information is included. Use a diction-
ary to ensure proper spelling. 9. Double-space. Start keying the body at
the left margin. Single-space within
NOTE: Ask your instructor for assis-
paragraphs; double-space between
tance, as needed.
paragraphs. Do not indent the first lines
4. Open a new document. Set the margins of paragraphs.
for the document. Note the center read-
NOTE: Most letters should contain at
ing.
least three paragraphs.
PROCEDURE 23:5
10. Double-space after the body. Key the and dental terms not included in the
complimentary close starting at the computer’s dictionary.
center line for MB or at the left margin
15. Print a hard copy of the letter. In most
for B. If more than one word is used,
agencies, a second copy of the letter is
capitalize only the first word. Insert a
placed in the patient’s file. Save the let-
comma at the end.
ter on the computer hard drive or on a
11. Leave four to five blank lines for the disk.
written signature.
12. Starting at the center line for MB or at
the left margin for B, key the sender’s
name and title. If it is long, the title can
be keyed on a second line.
13. Double-space. Key the reference initials,
starting at the left margin. Use either
Practice
capital or lowercase letters for the ini-
tials of either just the preparer or of both
Composing Business Letters, to
the sender and the preparer. If two sets
of initials are used, use a colon to sepa-
rate capitalized initials and a slash to believe you have mastered this skill,
separate lowercase initials. Some agen- sign the sheet and give it to your
cies use capital initials for the sender, instructor for further action.
lowercase initials for the preparer, and a
colon to separate the letters.
14. Read the entire letter. Perform a spelling Final Checkpoint Using the criteria
and grammar check. Use a dictionary as listed on the evaluation sheet, your
necessary to check spelling of medical instructor will grade your performance.
addresses, and contract numbers be correct.

22:6 INFORMATION Double-check this information as it is being
recorded. It is also wise to check each time the
Completing Insurance Forms patient visits the health care agency that the
Because many patients rely on insurance patient’s coverage has not changed.
companies to pay medical and/or dental If a patient wishes to file an insurance claim,
expenses, completing insurance forms may be make sure the patient has completed any parts of
a part of your duties. To obtain prompt payment the form that he or she is required to complete.
from the companies, you must complete the Also make sure that the patient has signed the
forms correctly. form wherever his or her signature is required. If
Information regarding a patient’s insurance the patient is a dependent, such as a spouse or
coverage is essential. Such information is usually older child, it is also necessary to obtain the sig-
obtained on the patient’s first visit to the agency. nature of the person to whom the insurance con-
The information is usually recorded on the statis- tract has been issued. This person is referred to as
tical data sheet, on the patient’s information card, the insured. HIPAA requirements mandate that
or in a computer database. In addition, most confidential medical information cannot be
agencies make a copy of both the front and back released unless a patient signs an authorization
of a patient’s insurance card and place the copy to release information to insurance companies.
in the patient’s file. It is essential that all names, Because most agencies now complete insurance
1000 CHAPTER 23
forms on a computer and file the claims electron- digits long. The first three digits represent a
ically, the patient and the insured usually sign an single disease or a group of closely related
“Authorization to Release Information and Assign conditions within a given disease classifica-
Benefits” form. This form is kept in the patient’s tion. A fourth digit further specifies the dis-
file and the insurance form is marked “patient’s ease, usually describing the location, cause, or
signature on file.” In some agencies, the form is stage of the disease. A fifth digit provides even
scanned into the computer and filed electroni- more information. For example, the code 812
cally with the insurance form. indicates a fracture of the humerus. The code
An all-purpose insurance claim form is now 812.0 indicates a fracture of the humerus,
used in many agencies (figure 23-14). This form, upper end, closed; and the code 812.1 indi-
known as the CMS-1500, was developed by the cates a fracture of the humerus, upper end,
Health Care Financing Administration. It must be open. The code 812.02 indicates a fracture of
used for any government-sponsored health care the humerus, upper end, closed, anatomical
claims, such as Medicare or Medicaid. All major neck. Note that if four or five digits are used, a
insurance companies will also accept this form. decimal point or period is used to separate the
last two digits from the first three digits. Every
diagnosis must be coded to the highest level of
CODING INSURANCE specificity or the claim will be rejected. There-
fore, it is important to use as many digits as
FORMS possible with each diagnosis. To find a diagno-
sis in the code book, look up the noun or main
Most insurance forms have two parts that
term in the alphabetical index. For example,
require codes: diagnosis and procedures/
look up hysterectomy for a diagnosis of subto-
services. Numerical codes are used to clearly iden-
tal hysterectomy. Use the code number in the
tify information in a uniform and standard man-
alphabetical index to find the exact ICD-9-CM
ner. Most insurance companies use computers
number in the tabular list for a subtotal hys-
and optical scanning equipment to process and
terectomy. Most computer programs also start
pay claims, so the numerical codes must be accu-
with the noun or main term. When the noun is
rate. Use of an incorrect code can lead to rejection
keyed into the computer, a list appears with
and/or delayed payment of a claim. There are two
subheadings and complete codes. By practic-
major sources of correct numerical codes:
ing using the code book or computer software,
♦ The World Health Organization (WHO) has you will find that it is not difficult to use.
developed a coding system for diagnoses to
aid in tracking the presence of the disease,
♦ WHO has developed the 10th revision of ICD
codes, and they are currently being evaluated
maintaining morbidity (affected with disease)
for adoption. Under HIPAA mandates, there
and mortality (causing death) statistics, and
will be a 2-year implementation period after
creating an international database for identi-
the final notice to implement the codes is
fying disease. This coding system is known as
published in the Federal Register. To accom-
the International Classification of Diseases
modate more diseases and provide more spe-
(ICD). The U.S. Department of Health and
cifics about a disease for tracking, WHO has
Human Services publishes the International
used alphanumeric (letters and numbers)
Classification of Diseases Clinical Modifica-
codes. Examples of the new codes for classifi-
tions (ICD-CM), which is used for diagnosis
cation of diseases of the appendix are shown
coding. The diagnosis is the identification of
in Table 23-1.
the disease or condition that the patient has. If
a patient is diagnosed as having more than ♦ The American Medical Association (AMA)
one condition, the most important diagnosis annually publishes The Physician’s Current
and its corresponding ICD-CM code are listed Procedural Terminology (CPT). This is the
first. Other diagnoses and their ICD-CM codes major source of numerical codes for proce-
follow in order of importance. Currently, the dures and services, called CPT codes. The
9th revision of ICD codes, or ICD-9-CM codes, American Dental Association (ADA) publishes
is being used to code diagnoses on insurance a Current Dental Terminology (ADA-CDT2)
forms. The ICD-9-CM codes are three to five book for use in dental offices. These codes are
FIGURE 23-14 Standard medical CMS-1500 insurance claim form.

1002 CHAPTER 23
TABLE 23-1 Sample ICD-10-CM Codes

SAMPLE ICD-10-CM CODES DISEASES OF THE APPENDIX: CLASSIFICATIONS K35-K38
K35 Acute appendicitis

K35.0 Acute appendicitis with generalized peritonitis
Appendicitis (acute) with:
• perforation
• peritonitis following rupture or perforation
• rupture
K35.1 Acute appendicitis with peritoneal abscess
Abscess of appendix
K35.9 Acute appendicitis, unspecified
Acute appendicitis with peritonitis, localized or NOS
Acute appendicitis without:
• generalized peritonitis
• perforation
• peritoneal abscess
• rupture
also available on computer tape for use in appendix. Usually, this is the only code
agencies where computers are used for billing required. However, if the appendectomy was
and insurance purposes (figure 23-15). It is very complex and involved much more time
important to use the latest edition of the book or care than is normally required, the modifier
or computer tape to be sure that the codes are -22 is added to the CPT code for a correct code
accurate and current. Each procedure or ser- of 44950-22. The introduction in the CPT code
vice is assigned a five-digit code without deci- book provides excellent instructions on the
mal points or periods. Modifiers are used to use of the book and on proper coding. By
further explain or to change the meaning of a reading the introduction and practicing using
code and are separated from the code by a the book, you can learn to correctly code pro-
dash. For example, the code 44950 indicates cedures and services (figure 23-16). In addi-
an appendectomy, or surgical removal of the tion, most agencies have lists containing
DOE, JOHN H. BC BC / BS OF FLA BELL BELLSOUTH DED. A
Select Diagnosis 8,297

1 271.1 letter and then
2 794.31 dia ← type bring up the
3 al listing of
4 DIABETES INSIPIDUS 253.5 codes.
DIABETES MELLITUS 250
FROM DIABETES MELLITUS OF MOTHER, WITH DELIVE 648.0 INSURANC PATIENT
DIABETES MELLITUS WITHOUT MENTION OF COM 250.0
11/19/08 DIABETES WITH HYPEROSMOLAR COMA 250.2 0.00 75.00
11/26/08 DIABETES WITH KETOACIDOSIS 250.1 0.00 33.00
DIABETES WITH NEUROLOGICAL MANIFESTATION 250.6
DIABETES WITH OPHTHALMIC MANIFESTATIONS 250.5
DIABETES WITH OTHER COMA 250.3
DIABETES WITH OTHER SPECIFIED MANIFESTAT 250.8
DIABETES WITH PERIPHERAL CIRCULATORY DIS 250.7
DIABETES WITH RENAL MANIFESTATIONS 250.4
ENTER TO SELECT [INS] TO ADD [F10] TO CHANGE

HOLD FOR [DEL] TO DELETE [F6] VIEW BY NUMBER 0.00 108.00
.00
[INS] [DEL] [F10] [F3] [F4] [F5] [F6] [F7] [F8]* [F9]
Next Proc. Delete Done Walkout HCFA 1500 Payment Transfer Hold Recall Path/Lab
FIGURE 23-15 ICD and CPT codes are available on computer tapes.
then keyed in box 12, the area designated for

the patient’s signature.
♦ Double-check for accuracy all names,
addresses, and contract numbers listed on the
form.
♦ Policy numbers or contract numbers fre-
quently include a letter or series of letters.
Make sure these numbers are accurate and
appear on the form in the proper places.
♦ Use correct codes, if codes are required. On
some forms, numerical codes are used for
place of services. For example, 11 indicates
provider’s office, 12 indicates home, 21 indi-
cates inpatient hospital, 22 indicates outpa-
tient hospital, and 32 indicates nursing home.
Numerical codes are also used to describe
type of service. For example, 1 indicates medi-
cal care, 2 indicates surgery, 4 indicates diag-
nostic X-rays, 5 indicates diagnostic laboratory,
and 9 indicates other medical services. The
codes required are usually listed on the form
FIGURE 23-16 Use the CPT and ICD books and/ or described in the software on a computer
or computer programs to ensure coding is correct program. Refer to these as necessary.
for both diagnoses and procedures.
♦ Answer all questions on the form. Do not leave
blank areas unless specifically instructed to
proper CPT codes for the common procedures do so. If a question does not apply, put NA or
and services provided. The CPT codes fre- a dash in the space.
quently are also printed on the communica- ♦ Answer all questions thoroughly and list spe-
tion form or superbill (discussed in Information cific information. For example, instead of put-
section 23:7), which simplifies the process of ting lab tests, list the tests that have been
completing insurance claims. performed.
♦ Standard abbreviations are allowed on most
COMPLETING forms. Ensure the accuracy of all abbrevia-
tions used.
INSURANCE CLAIMS ♦ Make sure the amounts charged are accurately
listed. Double-check all arithmetic.
Some general rules that apply to completing most
insurance forms are as follows: ♦ Make sure the physician or other authorized
person has signed the form in the required
♦ Make sure you are using the correct form. areas. Many forms require the physician’s
♦ Read the form thoroughly or review the soft- National Provider Number (NPI) and/or the
ware program on a computer to be sure you Physician’s Identifying Number (PIN). Medi-
understand what is required. care requires the use of the NPI number. The
♦ Check to be sure that the patient has com- NPI is a 10-digit number that is inserted in box
pleted the proper areas. Make sure his or her 33 of the CMS-1500 form. Make sure this num-
signature appears in all required spaces. If you ber is entered accurately.
are using a computer program to generate the ♦ Note the boxed area for assignment. If the
form, make sure the patient and insured have physician or agency will accept the amount
signed an authorization to release informa- allowed by the insurance company as pay-
tion and assign benefits form. This is often ment in full, this is marked yes; if not, it is
kept in the patient’s file. Signature on file is marked no.
1004 CHAPTER 23
♦ The form is generally copied and a copy placed The form can be printed and mailed, but many
in the patient’s file. agencies now file insurance forms electronically
on a secure modem. Electronic filing results in
♦ Recheck the entire form before mailing. faster processing and payment of the claim. These
In many agencies, computers programmed programs are easy to use and save a great deal of
to complete standard insurance claim forms time when processing insurance forms.
are used. A sample entry screen for recording
information is shown in figure 23-17. Informa- STUDENT: Go to the workbook and complete
tion for the insurance claim is entered into the the assignment sheet for 23:6, Completing Insur-
computer. The computer then prints the infor- ance Forms. Then return and continue with the
mation in the proper areas on the insurance form. procedure.
THIS IS A PREVIOUSLY ENTERED FORM 11/19/02 Pt Bal ⫽
Doctor [1] Assistant [ ] Assign? [N] Fee Code [A]
MEDICARE MEDICAID CHMPUS CHMPVA GROUP FECA OTHER Insured’s ID Number
[X] [ ] [ ] [ ] [ ] [ ] [ ] 123456789A
Insured’s Name
Patient’s Name Birthdate Sex (M/F)
John H. Doe
Doe, John H. 05/06/56 M
Address Insured’s Address
3508 SOUTH ATLANTIC AVE SelfX Spouse Child Other
NEW SMRYNA BEACH FL 32771
32771 427-0558 (904) Single Married Other
Other Insured’s Name Employd FullTS PartTS Insured’s Group
Policy Number Condition Related to: Ins. DOB Sex

65913222 Employment [ ] Yes [X] No / /
DOB Sex ST Employer
/ / Auto Acc. [ ] Yes [X] No
Employer Plan Name
Other Acc. [ ] Yes [X] No BC / BS OF FLA
Plan Name Date of Disability
BELLSOUTH DED. SERV CENTR Local
Date of Current First consulted
Hospitalization
Referring {F5} Referring ID#
—
Lab [ ] Yes [X] No
Facility {F5} Prior Auth
{F10} ⫽ Next Pg {ESC} ⫽ Back Up {F3} ⫽ Pt Info CTRL ⫹ ESC ⫽ Abort 11/19/08 1
FIGURE 23-17 A sample computer entry screen for insurance information.
PROCEDURE 23:6
Completing Insurance Procedure
Forms 1. Assemble equipment. Open the insur-
ance software program on the computer
NOTE: You must have keyboarding or
or obtain a sample insurance form from
typing skills to complete this proce-
your instructor.
dure.
2. Read the insurance form or review the
Equipment and Supplies entry areas on the computer program.
Make sure you understand all required
Computer with insurance coding software for information.
ICD and CPT codes, or typewriter with good
NOTE: Ask your instructor to explain
ribbon, sample insurance forms, correction
areas, as needed.
tape or fluid, International Classification of
Diseases (ICD) book, The Physician’s Current 3. Make sure that the patient has com-
Procedural Terminology (CPT) book (or ADA- pleted his or her portions of the form or
CDT-2 book for dental claims) has signed an authorization to release
PROCEDURE 23:6
information form. Check to be sure that obtained from the patient’s chart and/
correct signatures are on the form. Sig- or the physician or supervisor. Be sure
natures should be written in blue or the sources are accurate.
black ink. If the patient is a dependent,
8. Many forms require dates of total or
make sure the insured person has signed
partial disability. This is determined by
the form, if this is required.
the physician or other authorized per-
NOTE: If the form is computer gener- son (for example, a therapist). The time
ated, and the patient and/or insured a patient is disabled and unable to work
have signed authorization to release usually begins with the date of the onset
information forms, Signature on file is of the condition. Insert this date in the
keyed in the area designated for the sig- correct area. An authorized person then
nature. determines an approximate date when
the patient’s disability will end and the
4. Enter all patient information, usually
patient will be able to return to work.
including the full name and address of
Insert this date as the final date. If no
the insured (the person to whom the
disability is determined, leave the blocks
insurance contract is issued); the
blank or type NA in all spaces.
patient’s name, address (including zip
code), birthdate (written as six digits, 9. If the patient was referred by another
for example, 03/26/67), sex (put an X in physician or agency, insert the full name
the correct box), and relationship to of the referring source. The NPI number
insured (put an X in the correct box); the of the referring physician is placed in
group number or name; the contract or the ID Number space. Put NA or none in
identifying number; and other similar the blank if there was no referring
data. Double-check all entries for accu- source.
racy.
10. If services were provided to the patient
NOTE: If the contract number has let- in a hospital, record the dates of hospi-
ters, be sure they are included. talization in the correct blanks. If a labo-
ratory outside the hospital or health
5. Most policies require information about
care facility performed tests, note this
other insurance the patient may have.
information along with the charges for
Record this information in the correct
the tests.
spaces. If the patient does not have
other insurance, insert NA, for “not 11. Leave line 19 Reserved for Local Use
applicable,” or none in this space. blank.
6. Most forms contain questions about 12. In the diagnosis section of the form, list
whether the condition is related to the ICD code for the main or primary
employment or an accident. Workers’ diagnosis first followed by other diagno-
Compensation may cover an employ- ses in order of importance. Use the
ment-related condition; other insur- International Classification of Diseases
ance may cover a condition caused by to find the correct ICD code for each
an accident. Therefore, it is important to diagnosis. Make sure each diagnosis is
answer these questions correctly. Mark coded to the highest level of specificity.
yes or no, or insert an X in the correct Double-check all entries for accuracy.
box.
NOTE: Payment on a claim can be
7. Enter information regarding dates of delayed or rejected if an incorrect or
care. Correct information is usually nonspecific ICD code is used.
1006 CHAPTER 23
PROCEDURE 23:6
13. The CPT codes for any services or pro- 17. A boxed area is usually provided for
cedures provided should be listed in the information regarding assignment, or
services or treatment section of the form. whether the physician or agency will
Each service or procedure should be accept the amount allowed and paid by
listed separately with the most impor- the insurance company. Check either
tant service listed first. Dates should be yes or no, as determined by the physi-
obtained from the patient’s chart or cian or agency.
from an authorized person. Numerical
18. Insert all required information regard-
codes are frequently used to indicate
ing the physician or supplier, including
place of service. Common codes include
full name and title, address, telephone
11 for office, 21 for inpatient hospital, 22
number (if requested), NIP, PIN, Social
for outpatient hospital, 12 for patient’s
Security and/or ID or license number,
home, 31 for skilled-nursing facility, and
and other required information. Be sure
32 for nursing home. Numerical codes
the physician or authorized person
are also used to describe types of ser-
signs in the correct area.
vice. Common codes include 1 for
medical care, 2 for surgery, 3 for consul- CAUTION: Double-check all numbers
tation, 4 for diagnostic X-rays, 5 for diag- for accuracy.
nostic laboratory, and 9 for other 19. Recheck all information on the form.
medical services. Codes for both type Make sure that all required information
and place of service are listed on the is recorded and all answers are pro-
form or defined in the computer soft- vided.
ware. Use The Physician’s Current Proce-
dural Terminology to find the correct 20. Before filing the form electronically or
CPT code for each procedure or service. mailing the form to the insurance com-
Double-check the code before inserting pany, place a copy in the patient’s file for
it in the correct area. The diagnosis code reference, if this is the policy of your
column refers to the diagnoses listed in agency.
the diagnosis section. The correspond- 21. Replace all equipment.
ing number of the diagnosis for which
the service was given should be inserted
in this column.
14. List the charges for services rendered.
Make sure the numbers for dollars are
lined up in the correct spaces. Place the Practice
amounts for cents or 00 in the correct Go to the workbook and use the
columns. Total all charges. Recheck all evaluation sheet for 23:6,
math, especially addition. If the patient Completing Insurance Forms, to
has paid an amount, note this in the practice this procedure. When you
correct place. Subtract any amount paid believe you have mastered this skill,
by the patient from the total charge to sign the sheet and give it to your
obtain the balance due. instructor for further action.
15. Insert the physician’s Social Security or
tax identification number in the space
provided. Mark the appropriate box.
16. Insert the patient’s account number in listed on the evaluation sheet, your
the appropriate space. instructor will grade your performance.
piled in one folder, a monthly record of all

23:7 INFORMATION business is available.
Maintaining a Bookkeeping ♦ Statement–receipt record: This contains
information on past balance due, charges for
System treatment, payment received, and current bal-
PEGBOARD SYSTEM ance (figure 23-19). Many slips also have a
space to note the patient’s next appointment.
One common bookkeeping system is the When complete, the statement–receipt can be
pegboard system. The pegboard system is given to the patient to provide a record of pay-
also called a “write-it-once” system. Various ment or of balance due. In some agencies,
records are noted simultaneously. The pegboard another version of this record is being used.
system usually encompasses the following series This version is usually a three-layer form that
of records: notes all the previous information as well as
specific services and corresponding insurance
♦ Day sheet, or daily journal: This is a daily code numbers. Called a communication form,
record of all patients seen, all charges incurred, or a superbill (figure 23-20), this version serves
and all payments received (figure 23-18). Each as a statement for the insurance company.
day sheet also provides a total column, which One copy can be retained by the agency; the
can be used for bank deposit slips; a business second copy can be sent to the insurance
analysis summary; a section for daily and company (or attached to an insurance form)
monthly account totals; a proof of posting to serve as a claim form; and the third copy
section for verifying that account totals are can be given to the patient to serve as a pay-
accurate; and a section to record accounts ment receipt, a record of treatment or services,
receivable, or total amounts owed by patients. a bill for the balance due on the account, and
When a month’s supply of day sheets is com- an appointment card, if another appointment
RECORD OF DEPOSITS
47 20--- Office Hosp. Labor- Diag-

DAY SHEET (RECORD OF CHARGES AND RECEIPTS) PAGE NO OF DATE visits visits atory nostic
DATE
CREDITS PREVIOUS RECEIPT BUSINESS ANALYSIS SUMMARIES
DATE REFERENCE DESCRIPTION CHARGES BALANCE NAME
PYMNTS. ADJ. BALANCE NUMBER CASH CHECKS (OPTIONAL)
1
3/8 Helen 99214, ROA 80 00 80 00 Helen Baldwin 258 80 00 80.00
2
3/8 Christopher 99214, ROA 80 00 8 00 371 00 299 00 Christopher Likens 8 00 80.00
3
3/8 Mary ROA 47 00 47 00 Mary McDonald 152 47 00
4 259 80 00 80.00
3/8 Alan 99203, ROA 80 00 80 00 Alan Silverstein
5 153 80 00 80.00 10.00
3/8 Anna 99214, 99000, ROA 90 00 80 00 60 00 50 00 Anna Miller
6 80.00 25.00 100.00
3/8 Bryan 99214, 81000, 93000,
99000, 71010
205 00 205 00 Bryan Lake
7 154 10 00
3/8 Jesse ROA 10 00 10 00 Jesse Montgomery
8 64 48
3/8 Christopher OT, Medicaid 64 48 49 40 257 12 371 00 Christopher Likens
9 260 80 00 80.00
3/8 Joanna 99203, ROA 80 00 80 00 Joanna Phillips
10
11
12
13
14
15
16
17
1 2 3
18
19
20
21
22
23
24
25
26
27
28
COL. A COL. B-1 COL. B-2 COL. C COL. D
4
TOTALS THIS PAGE PREPARED
615 00 449 46 49 40 893 12 777 00 BY
PREVIOUS PAGE
TOTAL CASH
207 00
2,405 20 2,559 71 319 43 8,993 34 9,407 28 TOTAL CHECKS
242 48
MONTH-TO-DATE
TOTAL DEPOSIT
3,020 20 3,009 19 368 83 9,826 46 10,184 28 449 48
CASH CONTROL
Beginning Cash On Hand 43.85
Receipts Today (Col. B-1) 449.48
Total 493.33
PROVE OF POSTING ACCOUNTS RECEIVABLE CONTROL ACCOUNTS RECEIVABLE CONTROL Less Paid Outs ----
5
COL. D TOTAL $ 777.00 PREVIOUS DAY’S TOTAL $ 3,230.29 ACCTS. REC. 1ST OF MONTH $ 3,704.23 Less Bank Deposit 449.48
PLUS COL. A TOTAL $ 615.00 PLUS COL. A $ 615.00 PLUS COL. A MO TO DATE $ 3,020.20 CASH PAID OUT
SUBTOTAL $ SUBTOTAL $ SUBTOTAL $ $ Closing Cash On Hand 43.85
1392.00 3,825.29 6,724.43
LESS COLS. B-1 & B-2 $ 495.88 LES COLS. B-1 7 B-2 $ 498.85 LESS COLS. B-1 & B-2 MO. TO DATE $ 3,378.02 $
MUST EQUAL COL. C $ 893.12 TOTAL ACCTS. REC. $ 3,346.41 TOTAL ACCTS. REC. $ 3,346.41 $
FIGURE 23-18 The day sheet provides a daily record of patients seen, charges incurred, and payments
received.
1008 CHAPTER 23
is reproduced by photocopy or microfilm and

mailed to the patient as a monthly statement
(figure 23-21).
The procedure for recording patient visits,
treatments, charges, and payments on the peg-
board system is described in Procedure 23:7. In
FIGURE 23-19 A statement–receipt provides addition to recording patients’ visits and charges,
information on past balance due, charges, payment the pegboard system is also used to record pay-
received, and current balance. (Courtesy of Control- ments received. One example is an insurance
o-fax Office Systems, Waterloo, IA) company check for payment for services. The
same steps are followed, but in place of a treat-
ment, ROA, for “received on account,” is usually
noted under description. Balances are then deter-
mined, and all information is simultaneously
noted on the day sheet and ledger card. A receipt
may be mailed to the patient.
Many insurance companies have contracts
with health care providers that specify amounts
that will be paid for services. When the insurance
company sends payment, it usually sends an
Explanation of Benefits (EOB) form. This form
lists the amount charged by the health care pro-
vider, the negotiated or allowed amount accord-
FIGURE 23-20 A three-layer version of the KERRY PEOPLES, M.D.

101 Fitness Lane
statement–receipt form, the communication form, or Anywhere, U.S.A. 00000
superbill also lists treatments and insurance codes. Marsha Leonard
777 Pine Tree Lane
It can be used as the form for insurance claims Troy, Ohio 47100
or attached to insurance forms. (Courtesy of CREDITS CURRENT
Control-o-fax Office Systems, Waterloo, IA) DATE DESCRIPTION CHARGE PAYMENTS ADJ. BALANCE
BALANCE FORWARD→
8/31/XX Marsha Office visit 35. 00 35. 00

is scheduled. Use of this form eliminates the 8/31/XX Marsha SMAC w/CBC & diff 30. 00 65. 00
9/15/XX ROA - cash 15. 00 50. 00
need to type out specific insurance forms.
♦ Charge slip: On some pegboard systems,
these are a part of the statement–receipt
record. When the patient arrives at the agency,
his or her name is entered at the top. This sec-
tion of the record is torn off the statement–
receipt and attached to the patient’s chart.
The physician or other authorized individual
then notes the treatments and charges on this
slip while treating the patient. The slip is given
back to the receptionist, who can then use it to
post charges. 276L PLEASE PAY LAST AMOUNT IN THIS COLUMN ↑
♦ Ledger card: This is a total record of care

provided to a patient. It is also a financial
record of the patient’s account. A brief descrip- THIS IS A COPY OF YOUR ACCOUNT AS IT APPEARS ON YOUR LEDGER CARD
tion of services, charges, payments made, and FIGURE 23-21 The ledger card serves as a
current balance due is noted on the card. In financial record of the patient’s account and can be
some agencies, copies of the ledger cards are copied and mailed to the patient as a monthly
used in place of separate bills. The ledger card statement.
ing to the contract, the amount the insurance the name and address of the patient, the person
company pays, and the amount of money owed responsible for the account, family members in
by the patient. If the negotiated or allowed the account, and insurance information is entered
amount is less than the charged amount, an for each patient. This forms the database for the
adjustment must be made to the patient’s system. ICD and CPT codes used in the agency
account. For example, a patient is charged $150 are also programmed into the computer along
for a physical examination. The EOB form shows with a description of the codes and the fees
that the negotiated or allowed amount for this charged for each. Most software is programmed
procedure is $100. The insurance company pays to indicate a source of payment, such as cash,
$80 and the patient must pay $20. An adjustment check, or insurance. When a patient receives a
of $50 ($150 charge minus $100 allowed equals service, the patient’s account history is retrieved.
$50 adjustment) must be credited to the patient’s Information about the service is entered on a
account. This is usually done at the same time daily transaction screen (figure 23-22). When the
the insurance payment is recorded by putting $50 correct CPT codes are entered, the software auto-
in the adjustment column on the day sheet and matically calculates the current balance by using
subtracting it from total charges. the past balance in the account history and add-
At the end of a business day, the day sheet ing it to the new charges. If payment is made, the
provides a total record of all charges and pay- software deducts the payment and calculates the
ments and a method of checking accounts. Daily new balance. The account history or computer-
totals are obtained by adding the amounts of ized ledger card is updated automatically as
each column on the day sheet. The accuracy of entries are made. Printed copies of the account
the records can be checked immediately. Small can be given to the patient to show all charges,
total boxes in the Proof of Posting section at the payments made, and the current balance due. In
bottom of the sheet provide the correct formulas addition, the account history can be used for bill-
for determining that all entries are correct. A bank ing patients at regular intervals.
deposit slip is also provided, if payments received In addition to handling patient accounts,
are to be deposited. bookkeeping software will also create a daily
Because a series of records is recorded at journal (figure 23-23). This provides a financial
one time, it is important for the recorder to record showing patients seen, services provided,
use a ballpoint pen and print neatly while press- charges, payments made, and outstanding bal-
ing hard enough for all copies to record. If an ances. Most software will generate a deposit slip
error is made, it must be lined out neatly. Neither created from the totals entered as payment is
erasers nor correction fluid should be used made.
because these are financial records that may be
audited for tax or legal purposes. If a major error
Messages-
is made, it may be best to void the statement– Patient and Provider INFORMATION Starting Balance $ ________________
receipt record and start a new record. Neatness Patient Name ______________________ Account Number ______________
Relationship ______________________ Provider Number ______________
and accuracy are essential when using the peg- Voucher Number __________________ Treatment Date _____/_____/_____
board system. These are bookkeeping records; INSURANCE INFORMATION
Covered by Insurance _____ Service Place _____
therefore, they must be stored for reference. Spe- Plan Covering Treatment_____ Last Entered Diagnosis
Description is:
cial folders can be purchased for this purpose.
TREATMENT AND PAYMENT INFORMATION
Proc. Code Description Charge Receipt Primary Diag. Suffix
COMPUTERIZED
BOOKKEEPING SYSTEMS Totals New Balance
E - Edit, A - Abandon, S - Save, H - Save/Hold, F - Finished

Most health care facilities use computerized F1-New F2-Daily F3-Report F4-Update F5-Post F6-Pull F7-Mail F8-Recall F9-Notes
bookkeeping systems. There are many types
of software available, but most provide the same FIGURE 23-22 A daily transactions entry screen
basic functions. Most systems used begin with allows the health care provider to enter information
the creation of a patient’s account history or a about a patient’s treatments and maintain the
computerized ledger card. Information including patient’s account.
1010 CHAPTER 23
DAILY CHARGES AND RECEIPTS REPORT - March 8, 2008
Page 1
ACCOUNT PAT NAME TODAYS BILLED

DATE ACCNT # NAME PMT. SOURCE DOCTOR PROC DIAG VOUCHER CHARGES RECEIPTS BALANCE P I INS
03/08/08 2 Brown Rachael 1 82996 V22.2 2 $18.00 $0.00 $134.00 N N Y

03/08/08 4 Gonzales Joseph 1 93000 785.1 1 $36.00 $0.00 $36.00 N N Y
03/08/08 6 O’Brien Janet 1 85022 285.9 3 $23.00 $23.00 $75.00 N N N
03/08/08 9 Williams Ryan 1 90071 780.7 7 $44.00 $0.00 $144.00 N N Y
03/08/08 1 Takamoto Credit Adj. 1 MO2 5 ⫺$18.00 $0.00 $78.00 N N Y
03/08/08 10 Young David 2 73090 848.9 6 $54.00 $54.00 $0.00 N N N
03/08/08 15 Anderson Nancy 1 86300 075 4 $18.00 $0.00 $62.00 N N Y
03/08/08 12 Lightfoot James 2 92551 389.9 8 $36.00 $0.00 $36.00 N N Y
03/08/08 11 Roberts Debit Adj. 1 MO1 9 $0.00 ⫺$25.00 $75.00 N N N
03/08/08 13 Paulson Jon 2 95000 477.9 10 $44.00 $0.00 $144.00 N N Y
03/08/08 14 Bond PAYMENT 1 M91 11 $0.00 $75.00 $200.00 N N Y
TOTALS $255.00 $127.00

Total interest included in Charges $0.00
Total Debit Adjustments - $25.00
Total Credit Adjustments - $18.00
Mode of operation - Daily data only
FIGURE 23-23 Computerized bookkeeping systems will provide a daily transactions report similar to the
day sheet.
Most computerized billing systems are easy all systems should be programmed to record
to use. The computer guides the user through deleted transactions to prevent someone from
each step of entering financial information by deleting a transaction and stealing the money. A
providing directions or asking the user questions. final important point is to make sure daily tape,
However, the health care worker must still under- disk, or CD-ROM backups are made of all infor-
stand the basic principles of financial manage- mation and stored in a safe area in case of com-
ment used in the manual bookkeeping method puter failure.
to use the computerized program. In addition,
safeguards must be in place when this type of STUDENT: Go to the workbook and complete
system is used. Most agencies use password pro- the assignment sheet for 23:7, Maintaining a
tection so only authorized individuals are allowed Bookkeeping System. Then return and continue
access to the financial information. In addition, with the procedure.
PROCEDURE 23:7
Computerized bookkeeping systems
Maintaining a require the same type of entries. If you
Bookkeeping System are using a computerized program, fol-
low the instructions provided with the
Equipment and Supplies software to enter the information and
balance the accounts.
Pegboard base, day sheet, ledger cards, state-
ment–receipt forms or communication Procedure
forms, ballpoint pen, assignment sheet num-
ber 1 for 23:7, Maintaining a Bookkeeping 1. Assemble equipment. Review the vari-
System ous forms and note the areas on each.
NOTE: This procedure describes a man- 2. Place the day sheet on the pegboard.
ual pegboard system of bookkeeping. Use the pegs to secure it in position.
PROCEDURE 23:7
3. Place a supply of statement–receipt slip or form when he or she sees the
forms or a communication form on top patient.
of the day sheet. Position these so that
7. As each patient “leaves” the office, do
the top line of each form lines up with
the following:
the first recording line on the day sheet.
a. Record the treatments and total
4. Prepare the patient ledger cards. In most
charges listed on the charge slip or
agencies, this is done according to the
communication form.
head of the household’s name. If this is
the case, record the last name and then b. Insert the patient’s ledger card in the
first name of this individual on each correct position between the day
card. Complete the full address. Be sure sheet and statement–receipt form
to include the zip code because it is fre- (figure 23-24). Be sure to use the cor-
quently used for billing purposes. If the rect statement–receipt form.
agency requires a separate ledger card c. Under Description, list the services or
for each patient, fill out the ledger card treatments noted on the charge slip.
for each individual patient. Services or treatments are already
5. If the patient is new, enter two zeros (00) noted on communication forms.
under Current Balance. If this is a sec- Abbreviations are usually used. These
ond card for a patient whose first card is often are listed on the statement–
full, place the current balance from the receipt form.
old card in this space. d. Put the charges or amount due in the
6. Follow the instructions on assignment Charges space. Put dollars to the left
sheet number 1 for patients seen and of the line and cents to the right.
charges incurred. As each patient e. If the patient pays an amount, note
“enters” the office, do the following: this in the Payment area.
a. Pull the correct ledger card for the f. If an adjustment must be made to the
patient. charges, put the amount in the Adj
b. Insert the ledger card in position. column. Adjustments may be made
Make sure the last line of informa- for discounts or credits, but they are
tion is above the statement–receipt usually made because of contracts
form.
c. Fill in the date and the patient’s
name.
d. Put the current balance (the amount
the patient owes for previously ren-
dered services) noted on the ledger
card in the space labeled Previous
Balance on the charge slip.
e. Put the receipt number on the state-
ment–receipt form on the day sheet.
f. Tear off the charge slip or remove the
communication form. Attach this to FIGURE 23-24 The ledger card is inserted
the patient’s chart. The person ren- between the statement–receipt record and the
dering treatment will complete the day sheet on the pegboard. (Courtesy of
Control-o-fax Office Systems, Waterloo, IA)
1012 CHAPTER 23
PROCEDURE 23:7
between health care providers and to use for filing a claim or sent to the
insurance companies. The amount insurance company by the agency. The
of the adjustment is shown on the third copy is retained by the agency.
Explanation of Benefits (EOB) form
m. Check to make sure all information
provided by the insurance company.
has been recorded on the day sheet.
It is the difference between the health
care provider’s charge and the 8. If money is received on an account, fol-
amount negotiated or allowed by the low the same steps as before. However,
insurance company. Adjustments are record ROA (for “received on account”)
subtracted from charges. under Description. Note the amount as
a payment.
g. If no payment is made, draw lines
through these areas. 9. At the end of the day, total all account
columns on the day sheet. Enter the fig-
h. Record the payment on the day sheet.
ures in the Proof of Posting box and fol-
If a bank deposit slip is to be used,
low the instructions given to catch any
make sure it is folded back under the
possible errors. Total the deposit slips
Receipts area of the day sheet or posi-
and check these for accuracy.
tioned correctly for posting. If the
payment is by check, record the 10. Replace all equipment.
amount in the column labeled
Checks. If the payment is by cash,
record the amount in the column
labeled Cash. Double-check all fig-
ures.
NOTE: Print numbers clearly so there is
no chance of error. Practice
i. Add the previous balance and charges Use the evaluation sheet for 23:7,
together. Double-check your addi- Maintaining a Bookkeeping System,
tion. to practice this procedure. Complete
assignment sheet number 1 in the
j. Subtract any payment made from the
workbook and give it to your
total amount due (the amount
instructor. Note any corrections
obtained in step 7i). Record your final
made to this sheet before
figure in Current Balance.
completing assignment sheet
k. Remove the ledger card and check to number 2. Make up additional
be sure all entries are clear and cor- practice sessions, as needed. When
rect. you believe you have mastered this
l. Tear off the statement–receipt record skill, sign the evaluation sheet and
or remove the communication form give it to your instructor for further
and give it to the patient. If the patient action.
needs an appointment, the next
appointment can be recorded on this
receipt.
NOTE: If a communication form is used,
one copy is given to the patient. The Final Checkpoint Using the criteria
insurance copy of the communication listed on the evaluation sheet, your
form can be either given to the patient instructor will grade your performance.
authority (for example, the physician, dentist,

23:8 INFORMATION therapist, or agency head). Only this individ-
ual is allowed to sign his or her name. If any
Writing Checks, Deposit Slips, other person signs the name, this is forgery.
and Receipts ♦ Before issuing a completed check, all informa-
Maintaining accurate financial records may tion should be checked again for accuracy and
be part of your responsibilities as a health completeness.
care worker. Checks and receipts are important
documents, and they must be filled in accurately. When a check is received from a patient, it
Checks and receipts help provide a record of should be checked closely. Make sure the amount
financial transactions. is correct and noted the same way on both parts
A check is a written order for payment of of the check showing amount. Make sure the
money through a bank. A check is used in place patient has listed the correct individual or agency
of cash for payment. Terms associated with name as the payee. Check the date for accuracy.
checks include the following: Make sure the check has been signed by the
patient. Patients sometimes want to write checks
♦ Payee: the person receiving payment for more than the amounts due to obtain extra
♦ Originator or maker: the person writing the cash. It is usually not wise to accept these types of
check, or issuing payment checks. If the person has insufficient funds in his
♦ Endorsement: the signature of the payee; or her checking account, the agency will lose not
this is usually posted to the back of the check only the amount due, but also the additional cash
and is required before payment will be made given to the patient. Sometimes a patient will
by the bank write Payment in Full on a check. Do not accept
such a check unless it does pay the entire balance
Basic rules for completing checks include the due, including previous charges and current
following: charges.
♦ Checks must be written in ink, typed, or Checks received by an agency are usually
printed on a computer printer. Using pencil stamped For Deposit Only to the Account
allows alterations by a dishonest person. of. . . . This prevents anyone from cashing a check
if it is stolen. It also serves as a means of endors-
♦ Writing must be legible. All names and num- ing the check. If the payee wishes to cash the
bers must be clear. check, it must be endorsed with his or her written
♦ Spaces should be avoided in name or amount signature. If an endorsed check is lost before it
lines. Begin writing to the far left of the line. can be taken to the bank, however, anyone who
This prevents another person from adding finds the check will be able to cash it. If a written
another name or increasing the amount of signature is used as an endorsement, the check
money. should not be endorsed until the person takes it
♦ Check stubs or registers should be recorded to the bank. Federal regulations now require
before the check is written. A check stub or that all endorsements be within 1 inch of the
register is a record of information about a “trailing edge” (on the back and directly behind
check. It states the number of the check, the the left side of the front of the check) of all checks.
person to whom the check was written, and If an endorsement extends below this area, the
the amount of the check. financial institution may refuse payment on the
check.
♦ Use fractions in place of decimals to indicate A receipt is a record of money or goods
number of cents. For example, instead of writ- received. If a patient makes a payment, a receipt
ing $100.00 (easily changed to $1,000.00), write can be given to the patient as proof of payment.
$100 00/100. The receipt stub or a register entry provides the
♦ The check must include the correct sig- agency with proof that payment has been
nature of the maker, or originator. This received. All information must be completed
signature is recorded at the bank when a accurately and legibly. Again, ink must be used to
checking account is opened. In an agency, the prevent any alteration of the receipt. In some
signature is usually that of the person in agencies, a separate receipt book is used. In other
1014 CHAPTER 23
agencies, receipts are part of the daily log record currency to be deposited is added together
or pegboard system. and entered as one entry in this section.
Specific instructions for writing checks and ♦ Coins: All coins to be deposited are added
receipts are included in Procedures 23:8A and together and entered as one entry in this sec-
23:8C. Each step is important. All work should be tion.
checked for accuracy.
Deposit slips are also important in main- ♦ Checks: Checks are usually listed separately
taining accurate financial records (figure 23-25). and then added together for the total. Most
Any cash monies or checks received should be deposit slips have a series of lines on the back
deposited in the bank as soon as possible. Most for a large number of checks. Here, the checks
agencies deposit monies on a daily basis. This are again listed separately and are added
prevents loss or theft. In addition, most agencies together for a subtotal, which is then trans-
keep a copy of each deposit slip with the financial ferred to the front of the deposit slip in the
records. This can be used to verify deposits and/ space indicated.
or ascertain that a specific check has been depos- NOTE: Specific rules for completing deposit slips
ited. Deposit slips must be accurate. All addition are noted in Procedure 23:8B.
must be double-checked. Terms used on these
slips include the following: STUDENT: Go to the workbook and complete
assignment sheet number 1 for 23:8, Writing
♦ Currency: Currency is any money in bill form, Checks, Deposit Slips, and Receipts. Then return
such as $1 bills, $10 bills, and other bills. All and continue with the procedures.
List all items

separately
Inner City Health Care DEPOSIT SLIP CURRENCY

222 S. First Avenue COIN
CHECKS
Carlton, MI 11666
(814) 555-7155
20
TOTAL FROM
OTHER SIDE
First Bank
5411 Brown Rd.
TOTAL
Carlton, MI 11666 A122014932A
Front
Total
Enter on front side
Back
FIGURE 23-25 Deposit slips usually have an area on the back for recording a large number of checks.
PROCEDURE 23:8A
a. Make sure that the current balance of
Writing Checks the checking account is noted in the
NOTE: This procedure is to be completed Balance Brought Forward section.
using the problems found in assignment b. Fill in the number of the check. Most
sheet numbers 1 and 2 in the workbook. preprinted checks have the number
printed on both the check and the
Equipment and Supplies check stub.
Sample blank checks (copies provided in c. In the dollar ($) space, print in the
workbook); assignment sheets numbers 2 amount of the check. Write the dollar
and 3 for 23:8, Writing Checks, Deposit Slips, amount close to the dollar sign. Write
and Receipts; pen cents as a fraction, for example, .50 as
50/100, no cents as no/100 or 00/100.
NOTE: This procedure describes the
d. Fill in the month, day, and year.
manual writing of checks. Computer-
ized check writing systems require the same e. In the To space, write the name of the
types of entries. If you are using a computer- person or company to whom the
ized program, follow the instructions pro- check is being written. This is the
vided with the software. payee.
f. In the For space, write a brief reason
Procedure for the payment, for example, com-
puter supplies, or rent.
1. Assemble equipment. Review preceding
g. In the Deposits space, note the
information about writing checks. Use
amount of any deposit you make to
only ink or a computer printer to write
the account. Add this amount to the
checks.
balance brought forward to obtain
2. Follow the directions on assignment the new total balance. If no deposit
sheet number 2 for 23:8, Writing Checks, has been made since the last check
Deposit Slips, and Receipts. was written, put dashes in this space.
3. First complete the check stub or register Write the new total balance in the
entry (figure 23-26) so that you do not Balance space.
accidentally issue a check without mak- h. Fill in the amount of the check you
ing a written record. are writing.
444 23 39/100 Happy Doctor , M.D. No. 444

No. $
1 Healthy Lane
Date MARCH 8 20__ Fitness, OH 11133
Date MARCH 8 20 – –
To ACE SUPPLY CO.
Pay to the
ACE SUPPLY COMPANY 39/
For ECG PAPER Order of $ 23 100
TWENTY-THREE AND 39/

100
Balance Brought Forward 442 06 dollars
First Money Bank
– – 1 Rich Lane
Deposits
Wealthy, OH 11133
442 06 0098-5567
Balance
23 39 Memo EKG PAPER By
Amount this check
Balance Carried Forward 418 67
FIGURE 23-26 A sample check with the check stub or register at the left.
1016 CHAPTER 23
PROCEDURE 23:8A
i. Subtract the amount of the check you checking account belongs. Only the
are writing from the new total bal- authorized person is permitted to sign
ance. Record the difference in the the check. After you have completed
Balance Carried Forward space. all parts of the check, double-check all
NOTE: Double-check all addition and entries. If they are accurate, obtain the
subtraction. appropriate signature. The check will
not be valid without this signature.
j. Immediately place the final balance
amount in the Balance Brought For- CAUTION: Never sign a check unless
ward space of the next check stub so you are specifically authorized to do so
that the balance will be there when and your signature is on the account at
you write the next check. the bank. Otherwise, signing the check
is considered forgery.
4. Once the stub has been completed,
write the check. Print or write legibly. h. Recheck all parts of the check and
Use only ink or a computer printer. stub for accuracy.
a. If the number is not preprinted on 5. If you make an error on any part of the
the check, write the number of the check, do not erase. Write void on both
check in the No. space. the check and the stub. Then start over
with a new check and stub.
b. Put the month, day, and year in the
Date space. 6. Follow steps 3–5 to complete all parts of
assignment sheet number 2. Then turn
c. Write the payee’s name in the Pay to it in to your instructor for grading.
the Order of space. Write the person’s
name or company name completely. 7. Replace all equipment.
Begin writing to the far left of the line.
d. In the $ space, print the amount of the
check in numbers. Place the dollar
amount numbers close to the dollar
sign. Print cents amount as a fraction.
Do not leave blank spaces where other
Practice
Use the evaluation sheet for 23:8A,
numbers could be inserted. Writing Checks, to practice this
e. In the dollars space, write out in words procedure. Note any changes or
the amount of the check. Start at the corrections to the graded
far left of the line. Write the number of assignment sheet number 2. Then
dollars; express cents as a fraction. follow the steps in the procedure to
Draw a line from the end of your nota- complete assignment sheet number
tion to the printed word dollars to 3 for 23:8, Writing Checks, Deposit
avoid leaving space for any altera- Slips, and Receipts. When you
tions, for example, Two hundred believe you have mastered this skill,
thirty-six and 30/100 ——— dollars.
sign the evaluation sheet and give it
f. If there is a For or Memo space on the to your instructor for further action.
check, fill in a brief explanation of
why the check is being written, for
example, office supplies, rent, or
insurance payment. Final Checkpoint Using the criteria
g. The check must be signed on the sig- listed on the evaluation sheet, your
nature line by the person to whom the instructor will grade your performance.
PROCEDURE 23:8B
6. List each check separately on the Checks
Writing Deposit Slips lines. If additional space is needed, most
deposit slips have areas on the back to
Equipment and Supplies note checks. The subtotal from the back
is then noted on the front of the slip.
Assignment sheet numbers 2 and 3 for 23:8,
Writing Checks, Deposit Slips, and Receipts; 7. Add the amounts for currency, coins,
sample deposit slips (copies provided in and checks together, and write the sum
workbook); pen in the Total space. If none of the total is
to be kept as cash (that is, all of the
Procedure money is to be deposited), enter this
total amount two lines down in the Total
1. Assemble equipment. Record all infor- Deposit space.
mation in ink. NOTE: If some of the total is kept as
2. Read assignment sheet number 2 for cash, place this amount in the Less Cash
23:8, Writing Checks, Deposit Slips, and space. Subtract this amount from the
Receipts, to note the amount of the total to obtain the amount of the total
deposit to be made to the checking deposit.
account. NOTE: If cash is retained, a signature is
3. On the deposit slip (figure 23-27) fill in usually required on the deposit slip. The
the correct date. Put the month, day, person to whom the account belongs
and year. must sign in the space indicated.
4. Write the total amount in bills in the 8. Recheck all amounts for accuracy.
Currency space. Because no cents are Recheck all addition and subtraction.
involved, place two zeros in the far right- Make a copy of the deposit slip to keep
hand column. with financial records. Take the original
deposit slip, cash, and checks to the
5. Count the total amount in coins. Write bank for deposit. Make sure to obtain a
this amount in the Coin column. deposit receipt from the bank.
NOTE: Write dollar amounts to the left 9. Note the amount deposited on the check
of the line and cent amounts to the right stub of the next check to be written. Add
of the line. the balance and amount deposited
Happy Doctor, M.D. Currency

1 Healthy Lane
Coin
Fitness, OH 11133
Checks
Date ––
Signature
(If cash received)
TOTAL
First Money Bank
Less Cash
1 Rich Lane
Wealthy, OH 11133 TOTAL DEPOSIT
0098-5567
FIGURE 23-27 A sample deposit slip.

1018 CHAPTER 23
PROCEDURE 23:8B
together to get the total current balance.
The checkbook and stubs will then be
up to date and ready to use.
Practice
Use the evaluation sheet for 23:8B,
Writing Deposit Slips, to practice
this procedure. Review any changes
or corrections to the graded
assignment sheet number 2. Then
follow the steps in the procedure to
complete assignment sheet number
3 for 23:8, Writing Checks, Deposit
Slips, and Receipts. When you
sign the evaluation sheet and give it
to your instructor for further action.

PROCEDURE 23:8C
a. In the No. space, write the number of
Writing Receipts the receipt. On preprinted receipts,
this is often already done, and all
Equipment and Supplies receipts are numbered consecu-
tively.
Assignment sheet numbers 2 and 3 for 23:8,
Writing Checks, Deposit Slips, and Receipts; b. In the Date space, print the month,
sample receipts; pen day, and year.
c. In the To space, print the name of the
Procedure person or company to whom the
receipt is being issued.
1. Assemble equipment. Review preceding
information on writing receipts. Use ink d. In the For space, write a brief expla-
to record all transactions. nation of why the receipt is being
issued, for example, POA (for “pay-
2. Obtain information to be recorded on ment on account”), office supplies, or
the receipts from assignment sheet ROA (for “received on account”).
number 2, for 23:8, Writing Checks,
Deposit Slips, and Receipts. e. In the Amount space, print the dollar
amount for which the receipt is being
3. First complete the stub or register (fig- issued. Most offices also note whether
ure 23-28). In this way, you will not for- the payment was made by check or
get to record this information and will cash.
have a record of the receipt issued.
PROCEDURE 23:8C
No. No. 20 – –
Date Received From
To Dollars
For For
– –
Amount $
FIGURE 23-28 A sample receipt with the receipt stub or register at the left.
4. Complete the receipt as follows: 5. Recheck all parts of the receipt and stub
before issuing the receipt. Make sure the
a. Place the correct number of the
amounts are accurate in both places. Be
receipt in the No. space. This number
sure all writing is clear, legible, and
may be preprinted.
accurate.
b. Fill in the full date, including month,
day, and year.
c. Write the full name of the person or
company from whom payment was
received in the Received From space.
Write legibly. Start at the far left of the Practice
line. Use the evaluation sheet for 23:8C,
d. On the Dollars line, write out in Writing Receipts, to practice this
words the amount received. Start at procedure. Note any changes or
the far left of the line. Note any cents corrections to the graded
as a fraction. Draw a line from the assignment sheet number 2. Then
end of your notation to the printed follow the steps in the procedure to
word dollars. complete assignment sheet number
3 for 23:8, Writing Checks, Deposit
e. In the For space, write a brief reason
for the payment. Slips, and Receipts. When you
f. In the $ space, fill in the amount in sign the evaluation sheet and give it
numbers. Write close to the dollar to your instructor for further action.
sign. Record cents as a fraction. Note
whether payment was made by check
or cash.
g. Sign your name to show that you listed on the evaluation sheet, your
received the money or items. instructor will grade your performance.
1020 CHAPTER 23

Bionic peepers?
In the United States, more than 200,000 people have retinitis pigmentosa (RP). RP is the
name given to a group of inherited eye diseases that cause a gradual loss of vision leading to
blindness. These diseases affect the retina, the nerve sensitive layer of the eye that contains
the photoreceptor cells called cones and rods. Cones are sensitive to color and are used
mainly to provide vision when it is light. Rod cells are used for vision in dark or dimly lit
environments and also capture images to provide peripheral or side vision. RP causes a
gradual deterioration of these cells, eventually leading to blindness.
Researchers are trying to help individuals with RP see again by creating an artificial ret-
ina. It consists of a small implant containing electrodes that connect to the damaged photo-
receptors on the patient’s retina. The patient wears a pair of glasses that contains a video
camera. Signals from the camera are transmitted as electrical impulses to the implant, which
stimulates the photoreceptors to transmit the signals to the brain through the optic nerve.
The artificial retina has been implanted in a small group of patients and initial tests showed
it allowed patients to begin detecting light and sensing motion. Researchers are now testing
more advanced models of artificial retinas that provide many more electrodes to allow
patients to see images.
The artificial retina will not help patients with optic nerve damage, but it may help
restore vision to patients with RP and the more than 6 million people in the United States
who suffer from age-related macular degeneration, another disease that destroys the photo-
receptors of the eye.
maintain financial records for health care facili-

CHAPTER 23 SUMMARY ties, including records of services rendered, pay-
ments made, and balances due on accounts.
Business and accounting skills are used in By learning business and accounting skills,
many health care careers. In addition, many of the health care worker can choose from a variety
the skills can be used in the personal life of the of health care careers.
health care worker.
Proper use of the telephone, composing pro-
fessional business letters, completing insurance INTERNET SEARCHES
forms, and writing checks, receipts, and deposit
slips are skills that can be utilized by any indi- Use the suggested search engines in Chapter 12:4
vidual. They are also essential skills for those of this textbook to search the Internet for addi-
who work in medical or dental offices, private tional information on the following topics:
health care facilities, or business offices of major 1. Accounting methods: research accounting
health care providers. systems, bookkeeping systems, financial
Proper filing techniques result in excel- records, and fiscal reports
lent organization and allow for easy access to
2. Insurance: research specific insurance compa-
records. Proper scheduling of appointments
nies, health maintenance organizations, and
helps a health care facility function efficiently.
preferred provider organizations to determine
Maintaining patient records, such as statistical
their requirements for processing claims
data sheets and medical histories, is an impor-
tant aspect of patient care. Accuracy is essential 3. American Medical Association: find the AMA
because medical records are considered legal site to obtain information on insurance forms
documents. Bookkeeping systems are used to and other materials available for purchase
4. Banks: research different banks to compare 5. List five (5) sections on a medical history form.
different types of checking and savings Briefly describe the type of information in each
accounts section.
5. Suppliers: research business and accounting 6. Differentiate between a modified-block and a
supplies to compare the different types of block style letter.
bookkeeping supplies, appointment ledgers,
7. What is an ICD code? a CPT code? a NPI
business stationery, and computer software
number?
programs for bookkeeping, patient databases,
completing insurance forms, scheduling 8. Kaleigh Nartker visits the office with a com-
appointments, and writing checks plaint of abdominal pain. Her previous
account balance is $234.55. Charges for the
office visit are: consultation $85.00, complete
REVIEW QUESTIONS blood count $64.00, urinalysis $38.00, and ECG
$120.50. She pays $125.00 by check. What is her
new account balance?
1. List five (5) rules that must be observed while
filing records alphabetically. Create one (1)
example to describe each of the rules. For additional information on health careers
2. File the following numbers in correct numeri- in medical records, contact the following organi-
cal order: 08532, 008553, 03251, 0325, 0008564, zation:
00038, 081000, and 0566. ♦ American Health Information Management
Association
3. You work in a medical office for four (4)
233 N. Michigan Avenue
different doctors. Create a list of triage ques-
Chicago, IL 60601–5800
tions that you can use to determine whether a
Internet address: www.ahima.org
patient needs an immediate appointment.
4. Identify security measures that must be
followed when using electronic mail, cellular
phones, and fax machines.
APPENDIX A Career and
Technical Student
Organizations
(CTSOs)
Career and technical student organizations pro- ♦ HOSA (Health Occupations Students of Amer-
vide both secondary (high school) and post- ica)
secondary (after high school) career/technical
students with the opportunity to associate with ♦ Technology Students Association (TSA)
other students enrolled in the same programs or ♦ SkillsUSA
career areas. Some purposes of these organiza- Two organizations that supplement health-
tions are to: science technology education are discussed:
♦ Develop leadership abilities, citizenship skills, HOSA and SkillsUSA.
social competencies, and a wholesome atti-
tude about life and work
♦ Strengthen creativity, thinking skills, decision- HOSA
making abilities, and self-confidence HOSA (pronounced Hosa) is the national orga-
♦ Enhance the quality and relevance of educa- nization for secondary and post-secondary/
tion by developing the knowledge, skills, and collegiate students enrolled in health science
attitudes that lead to successful employment technology education (HSTE) programs. HOSA is
and continuing education endorsed by the U.S. Department of Education
and the Health Science Technology Education
♦ Promote quality of work and pride in occupa- Division of the Association for Career and Tech-
tional excellence through competitive activi-
nical Education (ACTE). Membership begins at
ties
the local level, where students who are enrolled
♦ Obtain scholarships for post-secondary edu- in an HSTE program join together under the
cation from corporations that recognize the supervision of their classroom instructor, who
importance of these organizations serves as the HOSA local chapter advisor. Local
The United States Department of Education chapters associate with the HOSA state associa-
recognizes and supports the following eight tion and the HOSA national organization.
career and technical student organizations: Members of HOSA are involved in commu-
nity-oriented, career-related, team-building, and
♦ Business Professionals of America (BPA) leadership-development activities. All HOSA
♦ Distributive Education Clubs of America activities relate to the classroom instructional
(DECA) program and the health care delivery system.
♦ Future Business Leaders of America (FBLA) Furthermore, HOSA is an integral part of the
HSTE program, meaning that HOSA activities
♦ National FFA Organization (Agriculture Sci- motivate students and enhance what the stu-
ence Education) dents learn in the classroom and on the job.
♦ Family, Career, and Community Leaders of The mission of HOSA is “to enhance the deliv-
America (FCCLA) ery of compassionate, quality health care by pro-
Career and Technical Student Organizations (CTSO’s) 1023
viding opportunities for knowledge, skills, and

leadership development of all HSTE students,
therefore helping the student meet the needs of
the health care community.” The HOSA motto is
“The hands of HOSA mold the health of tomor-
row.” The HOSA slogan is “Health Science and
HOSA: A Healthy Partnership.” Goals that HOSA
believes are vital for each member are:
♦ To promote physical, mental, and social well-
being
♦ To develop effective leadership qualities and
skills
♦ To develop the ability to communicate more
effectively with people
♦ To develop character
♦ To develop responsible citizenship traits
♦ To understand the importance of pleasing FIGURE A-1 The HOSA emblem. (Reprinted with
oneself as well as being of service to others permission of HOSA)
♦ To build self-confidence and pride in one’s medical technician, clinical and administrative
work
medical assisting, medical laboratory assisting,
♦ To make realistic career choices and seek suc- nursing assisting, practical nursing, physical
cessful employment in the health care field therapy aide, veterinary assisting, dental spelling
♦ To develop an understanding of the impor- and terminology, medical spelling and terminol-
tance of interacting and cooperating with ogy, extemporaneous health poster, community
other students and organizations awareness project (of health-related issues), cre-
ative problem solving, biomedical debate, parlia-
♦ To encourage individual and group achieve-
mentary procedure, and the HOSA Bowl.
ment
HOSA has an official emblem (figure A-1).
♦ To develop an understanding of current health The circle represents the continuity of health
care issues, environmental concerns, and sur- care; the triangle represents the three aspects of
vival needs of the community, the nation, and human well-being: social, physical, and mental;
the world and the hands signify the caring of each HOSA
♦ To encourage involvement in local, state, and member. The colors of HOSA—maroon, medical
national health care and education projects white, and navy blue—are represented in the
emblem. Navy blue represents loyalty to the
♦ To support HSTE instructional objectives
health care profession. Medical white represents
♦ To promote career opportunities in health purity of purpose. Maroon represents the com-
care passion of HOSA members.
In addition to providing activities that allow The HOSA handbook provides detailed infor-
members to develop occupational skills, leader- mation about the structure, purposes, competitive
ship qualities, and fellowship through social and events, and activities of HOSA. Students interested
recreational activities, HOSA also encourages in further details should refer to this handbook or
skill development and a healthy competitive obtain additional information from the Internet
spirit through participation in the National Com- by contacting HOSA at www.hosa.org.
petitive Events Program. Competition is held at
the local, district/regional, state, and national
levels. Some of the competitive events include
SkillsUSA
contests in prepared and extemporaneous speak- Students in HSTE programs can also participate
ing, job-seeking skills, CPR/first aid, dental assist- in SkillsUSA. SkillsUSA is a partnership of stu-
ing, dental laboratory technology, emergency dents, teachers, and industry working together to
1024 APPENDIX A
ensure America has a skilled workforce. It is a students develop the skills they need to make
national organization for secondary and post- a smooth transition to the workforce or higher
secondary/collegiate students enrolled in train- education.
ing programs in technical, skilled, and service SkillsUSA Championships offer skill compe-
occupations, including health careers. Examples tition in both leadership and occupational areas.
of these programs include auto services, cosme- Competition is held at the local, district/ regional,
tology, carpentry, collision repair, computer- state, and national levels. Examples of leadership
aided drafting, electronics, masonry, precision contests include prepared and extemporaneous
machining, welding, and health occupations. speech, SkillsUSA opening and closing ceremo-
Membership begins with local chapters that affil- nies, chapter business procedure, action skills,
iate with a state association and then the national job interview, and safety promotion. Examples of
organization. career contests for HSTE students include medi-
A national program of work sets the pace cal assisting, dental assisting, nurse assisting,
for SkillsUSA chapters. All SkillsUSA programs practical nursing, basic health care skills, first aid
are in some way related to these seven major and CPR, health occupations professional port-
goals: professional development, community folio, and a health knowledge bowl.
service, employment, ways and means, champi- The ceremonial emblem of SkillsUSA is shown
onships, public relations, and social activities. in figure A-2. The shield represents patriotism, or
The SkillsUSA motto is “Preparing for leader- a belief in democracy, liberty, and the American
ship in the world of work.” Some of the purposes way of life. The torch represents knowledge. The
include: orbital circles represent technology and the train-
ing needed to master new technical frontiers
♦ To unite in a common bond all students along with the need for continuous education.
enrolled in trade, industrial, technical, and The gear represents the industrial society and the
HSTE cooperation of the individual working with labor
♦ To develop leadership abilities through par- and management for the betterment of human-
ticipation in educational, technical, civic, rec- kind. The hands represent the individual and
reational, and social activities portray a search for knowledge along with the
♦ To foster a deep respect for the dignity of desire to acquire a skill.
work The colors of the SkillsUSA organization are
red, white, blue, and gold. Red and white repre-
♦ To assist students in establishing realistic sent the individual states and chapters. Blue rep-
goals resents the common union of the states and
♦ To help students attain purposeful lives
♦ To create enthusiasm for learning
♦ To promote high standards in trade ethics,
workmanship, scholarship, and safety
♦ To develop the ability of students to plan
together, organize, and carry out worthy activ-
ities and projects through the use of the dem-
ocratic process
♦ To develop patriotism through a knowledge of
our nation’s heritage and the practice of
democracy
To achieve these purposes, SkillsUSA offers a

Professional Development Program (PDP), and
SkillsUSA Championships. The PDP is a self-
paced curriculum for students to obtain skills in
areas such as effective communication, manage-
ment, teamwork, networking, workplace ethics, FIGURE A-2 The SkillsUSA emblem. (Reprinted
and job interviewing. The PDP is designed to help with permission of SkillsUSA)
Career and Technical Student Organizations (CTSO’s) 1025
chapters. Gold represents the individual, the

most important element of the organization. OTHER SOURCES
The SkillsUSA Leadership Handbook and
other SkillsUSA publications provide more infor-
OF INFORMATION
mation on the various activities and programs. ♦ National HOSA
Students interested in further details should refer 6021 Morris Rd., Suite 111
to these sources of information or obtain addi- Flower Mound, TX 75028
tional information from the Internet by contact- 800-321-HOSA
ing SkillsUSA at www.skillsusa.org. Internet address: www.hosa.org
♦ SkillsUSA
P.O. Box 3000
Leesburg, Virginia 20177-0300
703-777-8810
Internet address: www.skillsusa.org
APPENDIX B Correlation to
National Health
Care Skill
Standards
TABLE B-1 Correlation to National Health Care Skill Standards

Health Care Biotechnology
Diversified Health Core Therapeutic Diagnostic Health Support Research and
Occupations Chapter Standards Services Services Informatics Services Development
History and Trends X X X X X X

of Health Care
Health Care Systems X X X X X X
Careers in Health Care X X X X X X
Personal and
Professional Qualities X X X X X X
of a Health Care Worker
Legal and Ethical X X X X X X
Responsiblities
Medical Terminology X X X X X X
Anatomy and Physiology X X X X X X
Human Growth and X X X X X X
Development
Cultural Diversity X X X X X X
Geriatric Care X X X X X X
Nutrition and Diets X X X X X X
Computer Technology X X X X X X
in Health Care
Promotion of Safety X X X X X X
Infection Control X X X X X X
Vital Signs X X X X X
First Aid X X X X X X
Preparing for the X X X X X X
World of Work
Dental Assistant Skills X
Laboratory Assistant Skills X X X X
Medical Assistant Skills X X
Nurse Assistant Skills X X
Physical Therapy Skills X X
Business and
Accounting Skills X X X X X X
APPENDIX C Metric Conversion
Charts
The metric system is gradually replacing other ♦ To convert centimeters to feet, divide the
systems of measurement. The following informa- number of centimeters by 30.48.
tion and charts will assist you in converting mea-
surements. 3. Weight measurements:
1. Temperature measurements:
♦ To convert pounds to kilograms, divide the
number of pounds by 2.2 (1 kilogram 2.2
♦ To convert Fahrenheit (F) temperatures to pounds).
Celsius (centigrade) (C) temperatures, sub-
tract 32 from the Fahrenheit temperature
♦ To convert kilograms to pounds, multiply
the number of kilograms by 2.2.
and then multiply the result by 5/9, or
0.5556. 4. Liquid measurements:
♦ To convert Celsius (C) temperatures to ♦ Note that 1 cubic centimeter (cc) is equal to
Fahrenheit (F) temperatures, multiply the 1 milliliter (mL).
Celsius temperature by 9/5, or 1.8, and then ♦ To convert household measurements (for
add 32 to the total. example, cups, ounces, quarts, or pints) to
♦ The chart on the following page provides metric measurements, multiply the house-
some major temperature equivalents. hold measurement by the equivalent num-
ber of milliliters (mL). For example, 1
2. Linear measurements:
teaspoon equals 5 mL. Therefore, 3 tea-
♦ To convert inches to centimeters, multiply spoons converted to metric would be 3 5,
the number of inches by 2.54 (1 inch 2.54 or 15 mL.
centimeters).
♦ To convert metric measurements to house-
♦ To convert feet to centimeters, multiply the hold measurements, divide the metric
number of feet by 30.48 centimeters (1 foot measurement by the number of metric
30.48 centimeters). units in one of the household units. For
♦ To convert centimeters to inches, divide example, there are 30 mL in 1 ounce. There-
the number of centimeters by 2.54. fore, 180 mL converted to ounces would be
180 ÷ 30, or 6 ounces.
1028 APPENDIX C
Fahrenheit–Celsius (Centigrade) Equivalents Linear English—Metric Equivalents
F° C° F° C° F° C° 1 inch (in) 0.0254 meters (m) 2.54 centimeters (cm)

12 inches 1 foot (ft) 0.3048 meters (m)
32 0 102 38.9 116 46.7 30.48 centimeters (cm)
70 21.1 103 39.4 117 47.2 3 feet 1 yard (yd) 0.914 meters (m)
75 23.9 104 40 118 47.8 91.4 centimeters (cm)
80 26.7 105 40.6 119 48.3 5,280 feet 1 mile 1601.6 meters (m)
85 29.4 106 41.1 120 48.9 39.372 inches 3.281 feet 1 meter (m)
90 32.2 107 41.7 125 51.7 1.094 yards 1 meter (m)
95 35 108 42.2 130 54.4 0.621 miles 1 kilometer (km)
96 35.6 109 42.8 135 57.2
97 36.1 110 43.3 140 60 Liquid English—Metric Equivalents
98 36.7 111 43.9 150 65.6
1 drop (gtt) 0.0667 milliliters (mL)
98.6 37 112 44.4 212 100
15 drops (gtts) 1.0 milliliters (mL)
99 37.2 113 45
1 teaspoon (tsp) 5.0 milliliters (mL)
100 37.8 114 45.6
3 teaspoons 1 tablespoon (tbsp) 15.0 milliliters (mL)
101 38.3 115 46.1
1 ounce (oz) 30.0 milliliters (mL)
8 ounces (oz) 1 cup (cp) 240.0 milliliters (mL)
2 cups (cp) 1 pint (pt) 500.0 milliliters (mL)
2 pints (pt) 1 quart (qt) 1,000.0 milliliters (mL)
1029
APPENDIX D 24-Hour Clock

(Military Time)
Conversion Chart
TIME 24-HOUR TIME TIME 24-HOUR TIME
12:01 AM 0001 12:01 PM 1201

12:05 AM 0005 12:05 PM 1205
12:30 AM 0030 12:30 PM 1230
12:45 AM 0045 12:45 PM 1245
1:00 AM 0100 1:00 PM 1300
2:00 AM 0200 2:00 PM 1400
3:00 AM 0300 3:00 PM 1500
4:00 AM 0400 4:00 PM 1600
5:00 AM 0500 5:00 PM 1700
6:00 AM 0600 6:00 PM 1800
7:00 AM 0700 7:00 PM 1900
8:00 AM 0800 8:00 PM 2000
9:00 AM 0900 9:00 PM 2100
10:00 AM 1000 10:00 PM 2200
11:00 AM 1100 11:00 PM 2300
12:00 NOON 1200 12:00 MIDNIGHT 2400
Glossary
A adolescence—Period of development from 12 to 18

abbreviation—A shortened form of a word, usually just years of age; teenage years.
letters. adrenal—One of two endocrine glands located one
abdominal—Pertaining to the cavity or area in the front above each kidney.
of the body and containing the stomach, the small advance directive—A legal document designed to indi-
intestine, part of the large intestine, the liver, the gall- cate a person’s wishes regarding care in case of a termi-
bladder, the pancreas, and the spleen. nal illness or during the dying process.
abduction—Movement away from the midline. aerobic—Requiring oxygen to live and grow.
abrasion—Injury caused by rubbing or scraping the afebrile—Without a fever.
skin. affection—A warm or tender feeling toward another;
absorption—Act or process of sucking up or in; taking fondness.
in of nutrients. agar plate—Special laboratory dish containing agar, a
abuse—Any care that results in physical harm or pain, or gelatinous colloidal extract of a red alga, which is used
mental anguish. to provide nourishment for growth of organisms.
accelerator—A chemical substance that increases the agent—Someone who has the power or authority to act
rate of a chemical reaction; a catalyst. as the representative of another.
acceptance—The process of receiving or taking; agglutination—Clumping together, as in the clumping
approval; belief. together of red blood cells.
accreditation—Process where an educational program agnostic—Person who believes that the existence of God
is recognized and/or approved for meeting and main- cannot be proved or disproved.
taining standards that qualify its graduates for profes- air compressor—Machine that provides air under pres-
sional practice. sure; used in dental areas to provide air pressure to
acculturation—Process of learning the beliefs and operate handpieces and air syringe.
behaviors of a dominant culture and assuming some albino—Absence of all color pigments.
of the characteristics. alginate—Irreversible, hydrocolloid, dental impression
acidosis—A pathological condition resulting from a dis- material.
turbance in the acid–base balance in the blood and alignment—Positioning and supporting the body
body tissues. so that all body parts are in correct anatomical
activities of daily living (ADL)—Daily activities neces- position.
sary to meet basic human needs, for example, feeding, alimentary canal—The digestive tract from the esoph-
dressing, and elimination. agus to the rectum.
acupuncture—Puncturing the skin at specific points alopecia—Baldness.
with thin needles to relieve pain and/or treat disease. alternative therapy—Method of treatment used in
acute—Lasting a short period of time but relatively place of biomedical therapies.
severe (for example, an acute illness). alveolar process—Bone tissue of the maxilla and man-
addiction—State of being controlled by a habit, as can dible that contains alveoli (sockets) for the roots of the
happen with alcohol and drugs. teeth.
adduction—Movement toward the midline. alveoli—Microscopic air sacs in the lungs.
adenitis—Inflammation of a gland or lymph node. Alzheimer’s disease—Progressive, irreversible disease
adipose—Fatty tissue; fat. involving memory loss, disorientation, deterioration
Glossary 1031
of intellectual function, and speech and gait distur- aphasia—Language impairment; loss of ability to com-
bances. prehend or speak normally.
amalgam—Alloy (mixture) of various metals and mer- apical foramen—The opening in the apex of a tooth;
cury; restorative or filling material used primarily on allows nerves and blood vessels to enter tooth.
posterior teeth. apical pulse—Pulse taken with a stethoscope and near
ambulate—To walk. the apex of the heart.
amino acid—The basic component of proteins. apnea—Absence of respirations; temporary cessation of
amputation—The cutting off or separation of a body respirations.
part from the body. apoplexy—A stroke; see cerebrovascular accident.
anaerobic—Not requiring oxygen to live and grow; able appendicular skeleton—The bones that form the
to thrive in the absence of oxygen. limbs or extremities of the body.
analgesia—The state of inability to feel pain yet still application form—A form or record completed when
being conscious. applying for a job.
anaphylactic shock—An extreme, sometimes fatal, appointment—A schedule to do something on a par-
allergic reaction or sensitivity to a specific antigen, ticular day and time.
such as a medication, insect sting, or specific food. aquathermia pad—Temperature-controlled unit that
anatomy—The study of the structure of an organism. circulates warm liquid through a pad to provide dry
anemia—Disease caused by lack of blood or an insuffi- heat.
cient number of red blood cells. aqueous humor—Watery liquid that circulates in the
anesthesia—The state of inability to feel sensation, anterior chamber of the eye.
especially the sensation of pain. aromatherapy—Use of natural scents and smells to
anger—Feeling of displeasure or hostility; mad. promote health and well-being.
anorexia—Loss of appetite. arrhythmia—Irregular or abnormal rhythm, usually
anorexia nervosa—Psychological disorder involving referring to the heart rhythm.
loss of appetite and excessive weight loss not caused arterial—Pertaining to an artery.
by a physical disease. arteriole—Smallest branch of an artery; vessel that con-
anoxia—Without oxygen; synonymous with suffocation. nects arteries to capillaries.
antecubital—The space located on the inner part of the arteriosclerosis—Hardening and/or narrowing of the
arm and near the elbow. walls of arteries.
anterior—Before or in front of. artery—Blood vessel that carries blood away from the
anterior teeth—Teeth located toward the front of the heart.
mouth; includes incisor and cuspids. arthritis—Inflammation of a joint.
antibody—Substance, usually a protein, formed by the asepsis—Being free from infection.
body to produce an immunity to an antigen or patho- aspirate—To remove by suction.
gen. aspirating syringe—Special dental anesthetic syringe
antibody screen—Test that checks for antibodies in the designed to hold carpules or cartridges of medica-
blood prior to a transfusion. tion.
anticoagulant—Substance that prevents clotting of the aspiration—Process of inhaling food, fluid, or a foreign
blood. substance into the respiratory tract.
antigen—Substance that causes the body to produce assault—Physical or verbal attack on another person;
antibodies; may be introduced into the body or formed treatment or care given to a person without obtaining
within the body. proper consent.
antioxidants—Enzymes or organic molecules; help assistant—Level of occupational proficiency where an
protect the body from harmful chemicals called free individual can work in an occupation after a period of
radicals. education or on-the-job training.
antisepsis—Aseptic control that inhibits, retards growth associate degree—Degree awarded by a vocational–
of, or kills pathogenic organisms; not effective against technical school or community college after success-
spores and viruses. ful completion of a two-year course of study or its
anuria—Without urine; producing no urine. equivalent.
anus—External opening of the anal canal, or rectum. astigmatism—Defect or blurring of vision caused by
aorta—Largest artery in the body; carries blood away irregularity of the cornea of the eye.
from the heart. atheist—Person who does not believe in any deity.
aortic valve—Flap or cusp located between the left ven- atherosclerosis—Form of arteriosclerosis character-
tricle of the heart and the aorta. ized by accumulation of fats or mineral deposits on
apathy—Indifference; lack of emotion. the inner walls of the arteries.
apex—The pointed extremity of a conelike structure; the atrium—Also called an auricle; an upper chamber of the
rounded, lower end of the heart, below the ventricles; heart.
the bottom tip of a tooth. atrophy—Wasting away of tissue; decrease in size.
1032 GLOSSARY
audiologist—Individual specializing in diagnosis and bias—A preference that inhibits impartial judgment.
treatment of hearing disorders. bicuspids—Also called premolars; the teeth that pulver-
audiometer—Instrument used to test hearing and ize or grind food and are located between cuspids and
determine hearing defects. molars.
auditory acuity—Ability to perceive and comprehend bifurcated—Having two roots (as in teeth).
sound waves; hearing. bile—Liver secretion that is concentrated and stored in
aural temperature—Measurement of body tempera- the gallbladder; aids in the emulsification of fats dur-
ture at the tympanic membrane in the ear. ing digestion.
auricle—Also called the pinna; external part of the ear. binders—Devices applied to hold dressings in place,
auscultation—Process of listening for sounds in the provide support, apply pressure, or limit motion.
body. bioethics—Branch of medicine concerned with moral
autoclave—Piece of equipment used to sterilize articles issues resulting from technologic advances and medi-
by way of steam under pressure and/or dry heat. cal research.
automated external defibrillator (AED)—Machine biohazardous—Contaminated with blood or body fluid
used to assess the heart rhythm and provide an elec- and having the potential to transmit disease.
tric shock to restore normal heart rhythm. biopsy—Excision of a small piece of tissue for micro-
autonomic nervous system—That division of the ner- scopic examination.
vous system concerned with reflex, or involuntary, bioterrorism—The use of biological agents, such as
activities of the body. pathogens, for terrorist purposes.
autopsy—Examination of the body after death to deter- bite-wing—Also called a cavity-detecting X-ray; a dental
mine the cause of death. radiograph that shows only the crowns of the teeth.
avulsion—A wound that occurs when tissue is separated bladder—Membranous sac or storage area for a secre-
from the body. tion (gallbladder); also, the vesicle that acts as the res-
axial skeleton—The bones of the skull, rib cage, and ervoir for urine.
spinal column; the bones that form the trunk of the bland diet—Diet containing only mild-flavored foods
body. with soft textures.
axilla—Armpit; that area of the body under the arm. block style—Letter format in which all parts of the letter
Ayer blade—Wooden or plastic blade used to scrape start at the left margin.
cells from the cervix of the uterus; used for Pap tests. blood—Fluid that circulates through the vessels in the
body to carry substances to all body parts.
B blood pressure—Measurement of the force exerted by
bachelor’s degree—Degree awarded by a college or the heart against the arterial walls when the heart con-
university after a person has completed a four-year tracts (beats) and relaxes.
course of study or its equivalent. blood smear—A drop of blood spread thinly on a slide
backup—Copying or saving data in a secure location to for microscopic examination.
prevent loss in the event of computer failure or a disas- bloodborne—An infectious disease or pathogenic
ter. organism that is transmitted through blood.
bacteria—One-celled microorganisms, some of which body—Main content, or message part, of a letter.
are beneficial and some of which cause disease. body mechanics—The way in which the body moves
bandage—Material used to hold dressings in place, and maintains balance; proper body mechanics
secure splints, and support and protect body parts. involves the most efficient use of all body parts.
bandage scissors—Special scissors with a blunt lower bolus—Food that has been chewed and mixed with
end used to remove dressings and bandages. saliva.
bargaining—Process of negotiating an agreement, sale, bowel—The intestines.
or exchange. Bowman’s capsule—Part of the renal corpuscle in the
Bartholin’s glands—Two small mucous glands near kidney; picks up substances filtered from the blood by
the vaginal opening. the glomerulus.
basal metabolism—The amount of energy needed to brachial—Pertaining to the brachial artery in the arm,
maintain life when the subject is at complete rest. which is used to measure blood pressure.
base—Protective (dental) material placed over the pulpal bradycardia—Slow heart rate, usually below 60 beats
area of a tooth to reduce irritation and thermal shock. per minute.
base of support—Standing with feet 8–10 inches apart bradypnea—Slow respiratory rate, usually below 10 res-
to provide better balance. pirations per minute.
battery—Unlawfully touching another person without brain—Soft mass of nerve tissue inside the cranium.
that person’s consent. brand name—Company or product name given to a
bed cradle—A device placed on a bed to keep the top medication or product.
bed linens from contacting the legs and feet. breast—Mammary, or milk, gland located on the upper
benign—Not malignant or cancerous. part of the front surface of the body.
Glossary 1033
bronchi—Two main branches of the trachea; air tubes to carpal—Bone of the wrist.
and from the lungs. carpule—A glass cartridge that contains a premeasured
bronchioles—Small branches of the bronchi; carry air amount of anesthetic solution; used for dental anes-
in the lungs. thesia.
buccal surface—Outside surface of the posterior teeth; catalyst—A chemical substance that increases the rate
surface facing the cheek; facial surface of bicuspids of a chemical reaction; an accelerator.
and molars. cataract—Condition of the eye where the lens becomes
budget—An itemized list of income and expected expen- cloudy or opaque, leading to blindness.
ditures for a period of time. catheter—A rubber, metal, or other type of tube that is
buffer period—Period of time kept open on an appoint- passed into a body cavity and used for injecting or
ment schedule to allow for emergencies, telephone removing fluids.
calls, and other unplanned situations. caudal—Pertaining to any tail or tail-like structure.
bulimarexia—Psychological condition in which a per- cavitation—The cleaning process employed in an ultra-
son eats excessively and then uses laxatives or vomits sonic unit; bubbles explode to drive cleaning solution
to get rid of the food. onto article being cleaned.
bulimia—Psychological condition in which a person cavity—A hollow space, such as a body cavity (which
alternately eats excessively and then fasts or refuses to contains organs) or a hole in a tooth.
eat. cell—Mass of protoplasm; the basic unit of structure of
burn—Injury to body tissue caused by heat, caustics, all animals and plants.
radiation, and/or electricity. cell membrane—Outer, protective, semipermeable
burs—Small, rotating instruments of various types; used covering of a cell.
in dental handpieces to prepare cavities for filling with cellulose—Fibrous form of carbohydrate.
restorative materials. cement—Dental material used to seal inlays, crowns,
bridges, and orthodontic appliances in place.
C cementum—Hard, bonelike tissue that covers the out-
calcaneus—Large tarsal bone that forms the heel. side of the root of a tooth.
calculus—Also called tartar; hard, calcium-like deposit central nervous system—The division of the nervous
that forms on the teeth; a stone that forms in various system consisting of the brain and spinal cord.
parts of the body from a variety of different sub- central processing unit (CPU)—Unit that controls all
stances. of the work of a computer; frequently called the
calorie—Unit of measurement of the fuel value of food. “brains” of the computer.
cancer—A group of diseases caused by abnormal cell centrifuge—A machine that uses centrifugal (driving
division and/or growth. away from the center) force to separate heavier mate-
cane—A rod used as an aid in walking. rials from lighter ones.
capillary—Tiny blood vessel that connects arterioles centrosome—That area of cell cytoplasm that contains
and venules and allows for exchange of nutrients and two centrioles; important in reproduction of the cell.
gases between the blood and the body cells. cerebellum—The section of the brain that is dorsal to
carbohydrate-controlled diet—Diet in which the the pons and medulla oblongata; maintains balance
number and types of carbohydrates are restricted or and equilibrium.
limited. cerebrospinal fluid—Watery, clear fluid that surrounds
carbohydrates—Group of chemical substances includ- the brain and spinal cord.
ing sugars, cellulose, and starches; nutrients that pro- cerebrovascular accident—Also called a stroke or
vide the greatest amount of energy in the average diet. apoplexy; an interrupted supply of blood to the brain,
carcinogen—Any cancer-causing substance. caused by formation of a clot, blockage of an artery, or
carcinoma—Malignant (cancerous) tumor of connec- rupture of a blood vessel.
tive tissue. cerebrum—Largest section of brain; involved in sensory
cardiac—Pertaining to the heart. interpretation and voluntary muscle activity.
cardiac arrest—Sudden and unexpected stoppage of certification—The issuing of a statement or certificate
heart action. by a professional organization to a person who has
cardiopulmonary—Pertaining to the heart and lungs. met the requirements of education and/or experience
cardiopulmonary resuscitation (CPR)—Procedure and who meets the standards set by the organization.
of providing oxygen and chest compressions to a vic- cervical—Pertaining to the neck portion of the spinal
tim whose heart has stopped beating. column or to the lower part of the uterus.
cardiovascular—Pertaining to the heart and blood ves- cervix—Anatomical part of a tooth where the crown
sels. joins with the root; entrance to or lower part of the
caries—Tooth decay, an infectious disease that destroys uterus.
tooth tissue. chain of infection—Factors that lead to the transmis-
carious lesion—An occurrence of tooth decay. sion or spread of disease.
1034 GLOSSARY
character—The quality of respirations (for example, compensation—Something given or received as an

deep, shallow, or labored). equivalent for a loss, service, or debt; defense mecha-
charge slip—A record on which charges or costs for ser- nism involving substitution of one goal for another
vices are listed. goal to achieve success.
check—A written order for payment of money through a competent—Able, capable.
bank. complementary therapy—Method of treatment used
chemical—The method of aseptic control in which sub- in conjunction with biomedical therapies.
stances or solutions are used to disinfect articles; does complete bed bath—A bath in which all parts of a
not always kill spores and viruses. patient’s body are bathed while the patient is confined
chemical abuse—Use of chemical substances without to bed.
regard for accepted practice; dependence on alcohol complimentary close—Courtesy closing of a letter (for
or drugs. example, Sincerely).
chemotherapy—Treatment of a disease by way of composite—The dental restorative or filling material
chemical agents. used most frequently on anterior teeth.
Cheyne–Stokes respirations—Periods of difficult compress—A folded wet or dry cloth applied firmly to a
breathing (dyspnea) followed by periods of no respira- body part.
tions (apnea). computer-assisted instruction (CAI)—Teaching
chiropractic—System of treatment based on manipula- method in which a computer and computer programs
tion of the spinal column and other body structures. are used to control the learning process and deliver
cholelithiasis—Condition of stones in the gallbladder. the instructional material to the learner.
cholesterol—Fatlike substance synthesized in the liver computerized tomography (CT)—A scanning and
and found in body cells and animal fats. detection system that uses a minicomputer and dis-
choroid—Middle or vascular layer of the eye, between play screen to visualize an internal portion of the
the sclera and retina. human body; formerly known as CAT (computerized
chromatin network—That structure in the nucleus of a axial tomography).
cell that contains chromosomes with genes, which concave—Curved inward; depressed.
carry inherited characteristics. confidential—Not to be shared or told; to be held in
chronic—Lasting a long period of time; reoccurring. confidence, or kept to oneself.
cilia—Hairlike projections. congenital—Present at birth (as in a congenital defect).
circumduction—Moving in a circle at a joint, or moving conjunctiva—Mucous membrane that lines the eyelids
one end of a body part in a circle while the other end and covers the anterior part of the sclera of the eye.
remains stationary. connective tissue—Body tissue that connects, sup-
citizenship—Status of being a citizen (including associ- ports, or binds body organs.
ated duties, rights, and privileges). constipation—Difficulty in emptying the bowel; infre-
clavicle—Collarbone. quent bowel movements.
clean—Free from organisms causing disease. constrict—To contract or narrow; to make smaller.
clear-liquid diet—Diet containing only water-based consultation—Process of seeking information or advice
liquids; nutritionally inadequate. from another person.
client—Person receiving service or care; a patient in contagious—Easily spread; communicable.
health care. contamination—Containing infection or infectious
clinic—Institution that provides care for outpatients; a organisms or germs.
group of specialists working in cooperation. contra angle—Attachment used on dental handpieces
closed bed—Bed that is made following the discharge of to cut and polish.
a patient. contract—To shorten, decrease in size, or draw together;
coccyx—The tailbone; lowest bones of the vertebral col- an agreement between two or more persons.
umn. contracture—Tightening or shortening of a muscle.
cochlea—Snail-shaped section of the inner ear; contains contusion—An injury that results in a hemorrhage
the organ of Corti for hearing. (bleeding) beneath intact skin; a bruise.
collection—To receive; a letter requesting payment on conventional-speed handpiece—Low-speed hand-
an account. piece in dental units; used to remove caries and for
colon—The large intestine. fine-finishing work.
colostomy—An artificial opening into the colon; allows convex—Curved outward; projected.
for the evacuation of feces. convulsion—Also called a seizure; a violent, involuntary
communicable disease—Disease that is transmitted contraction of muscles.
from one individual to another. cornea—The transparent section of the sclera; allows
communication—Process of transmission; exchange light rays to enter the eye.
of thoughts or information. cortex—The outer layer of an organ or structure.
Glossary 1035
cost containment—Procedures used to control costs or defecation—Evacuation of fecal material from the
expenses. bowel; a bowel movement.
Cowper’s glands—The pair of small mucous glands defense mechanism—Physical or psychological reac-
near the male urethra. tion of an organism used in self-defense or to protect
cranial—Pertaining to the skull or cranium. self-image.
cranium—Part of the skull; the eight bones of the head defibrillate—Use of an electric shock to restore normal
that enclose the brain. heart rhythm.
criticism—Judgment regarding worth; censure, disap- dehydration—Insufficient amounts of fluid in the tis-
proval; evaluation. sues.
cross index/reference—A paper or card used in filing delirium—Acute, reversible mental confusion caused
systems to prevent misplacement or loss of records. by illness, medical problems, and/or medications.
cross-match—A blood test that checks the compatibil- delusion—A false belief.
ity of the donor’s blood and the recipient’s blood before dementia—Loss of mental ability characterized by
a transfusion. decrease in intellectual ability, loss of memory,
crown—The anatomical portion of a tooth that is exposed impaired judgment, and disorientation.
in the oral cavity, above the gingiva, or gums. denial—Declaring untrue; refusing to believe.
crust—A scab; outer covering or coat. dental chair—Special chair designed to position a
crutches—Artificial supports that assist a patient in patient comfortably while providing easy access to the
walking. patient’s oral cavity.
cryotherapy—Use of cold applications for treatment. dental hygienist—A licensed individual who works
cultural assimilation—Absorption of a culturally dis- with a dentist to provide care and treatment for the
tinct group into a dominant or prevailing culture. teeth and gums.
cultural diversity—Differences among individuals dental light—Light used in dental units to illuminate
based on cultural, ethnic, and racial factors. the oral cavity.
culture—Values, beliefs, ideas, customs, and character- dentin—Tissue that makes up the main bulk of a tooth.
istics passed from one generation to the next. dentist—A doctor who specializes in diagnosis, preven-
culture specimen—A sample of microorganisms or tis- tion, and treatment of diseases of the teeth and gums.
sue cells taken from an area of the body for examina- dentition—The number, type, and arrangement of teeth
tion. in the mouth.
cuspid—Also called a canine or eyetooth; the type of denture—An entire set of teeth; usually refers to artifi-
tooth located at angle of lips and used to tear food. cial teeth designed to replace natural teeth.
custom tray—Dental impression tray specially made to dependable—Capable of being relied on; trustworthy.
fit a particular patient’s mouth. deposit slip—A bank record listing all cash and checks
cyanosis—Bluish color of the skin, nail beds, and/or lips that are to be placed in an account, either checking or
due to an insufficient amount of oxygen in the blood. savings.
cystitis—Inflammation of the urinary bladder. depression—Psychological condition of sadness, mel-
cystoscope—Instrument for examining the inside of the ancholy, gloom, or despair.
urinary bladder. dermis—The skin.
cytoplasm—The fluid inside a cell; contains water, pro- development—Changes in the intellectual, mental,
teins, lipids, carbohydrates, minerals, and salts. emotional, social, and functional skills that occur over
time.
D diabetes mellitus—Metabolic disease caused by an
dangling—Positioning the patient in a sitting position insufficient secretion or utilization of insulin and lead-
with his or her feet and legs over the side of the bed ing to an increased amount of glucose (sugar) in the
prior to ambulation. blood and urine.
day sheet—A daily record listing all financial transac- diabetic coma—An unconscious condition caused by
tions and/or patients seen. an increased level of glucose (sugar) and ketones in
daydreaming—Defense mechanism of escape; dream- the bloodstream of a person with diabetes mellitus.
like musing while awake. diagnosis—Determination of the nature of a person’s
deciduous teeth—Also called primary teeth; the first set disease.
of 20 teeth. dialysis—Removal of urine substances from the blood
decubitus ulcer—See pressure (decubitus) ulcer. by way of passing solutes through a membrane.
deduction—Something subtracted or taken out (for diaphoresis—Profuse or excessive perspiration, or
example, monies taken out of a paycheck for various sweating.
purposes). diaphysis—The shaft, or middle section, of a long bone.
defamation—Slander or libel; a false statement that diarrhea—Frequent bowel movements with watery
causes ridicule or damage to a reputation. stool.
1036 GLOSSARY
diastole—Period of relaxation of the heart. dyspnea—Difficult or labored breathing.

diastolic pressure—Measurement of blood pressure dysrhythmia—An abnormal rhythm in the electrical
taken when the heart is at rest; measurement of the activity of the brain or heart.
constant pressure in arteries. dystrophy—Progressive weakening (atrophy) of a body
diathermy—Treatment with heat. part, such as a muscle.
diencephalon—The section of the brain between the dysuria—Difficult or painful urination.
cerebrum and midbrain; contains the thalamus and
hypothalamus. E
dietitian—An individual who specializes in the science early adulthood—Period of development from 19 to 40
of diet and nutrition. years of age.
differential count—Blood test that determines the per- early childhood—Period of development from 1 to 6
centage of each kind of leukocyte (white blood cell). years of age.
digestion—Physical and chemical breakdown of food by echocardiography—A diagnostic test that uses ultra-
the body in preparation for absorption. high-frequency sound waves to evaluate the structure
digital—Pertaining to fingers or toes; examination with and function of the heart.
the fingers. edema—Swelling; excess amount of fluid in the tissues.
dilate—Enlarge or expand; to make bigger. ejaculation—Expulsion of seminal fluid from the male
direct smear—A culture specimen placed on a slide for urethra.
microscopic examination. ejaculatory duct—In the male, duct or tube from the
disability—A physical or mental handicap that inter- seminal vesicle to the urethra.
feres with normal function; incapacitated, incapable. electrocardiogram (ECG)—Graphic tracing of the
discretion—Ability to use good judgment and self- electrical activity of the heart.
restraint in speech or behavior. electroencephalogram (EEG)—Graphic recording of
disease—Any condition that interferes with the normal the brain waves or electrical activity in the brain.
function of the body. electronic mail (e-mail)—Form of communication
disinfection—Aseptic-control method that destroys that is sent, received, and forwarded online from one
pathogens but does not usually kill spores and computer to another by means of a modem.
viruses. emblem—A symbol; identifying badge, design, or
dislocation—Displacement of a bone at a joint. device.
disorientation—Confusion with regard to the identity embolus—A blood clot or mass of material circulating in
of time, place, or person. the blood vessels.
displacement—Defense mechanism in which feelings embryo—Unborn infant during the first 3 months of
about one person are transferred to someone else. development.
distal—Most distant or farthest from the trunk; center or emesis—Vomiting; expulsion of the contents of the
midline. stomach and/or intestine through the mouth and/or
distal surface—Side surface of teeth that is toward the nose.
back of the mouth, or away from the midline of the emotional—Pertaining to feelings or psychological
mouth. states.
diuretics—Drugs that increase urinary output; “water empathy—Identifying with another’s feelings but being
pills.” unable to change or solve the situation.
doctorate—Degree awarded by a college or university enamel—Hardest tissue in the body; covers the outside
after completion of a prescribed course of study of the crown of a tooth.
beyond a bachelor’s or master’s degree. endocardium—Serous membrane lining of the heart.
dorsal—Pertaining to the back; in back of. endocrine—Ductless gland that produces an internal
dorsal recumbent position—The patient lies on the secretion discharged into the blood or lymph.
back with the knees flexed and separated; used for endodontics—Branch of dentistry involving treatment
vaginal and pelvic examinations. of the pulp chamber and root canals of the teeth; root
douche—See vaginal irrigation. canal treatment.
dressing—Covering placed over a wound or injured endogenous—Infection or disease originating within
part. the body.
dry cold—Application that provides cold temperature endometrium—Mucous membrane lining of the inner
but is dry against the skin. surface of the uterus.
dry heat—Application that provides warm temperature endoplasmic reticulum—Fine network of tubular
but is dry against the skin. structures in the cytoplasm of a cell; allows for the
duodenum—First part of the small intestine; connects transport of materials in and out of the nucleus and
the pylorus of the stomach and the jejunum. aids in the synthesis and storage of protein.
dyspepsia—Difficulty in digesting food; indigestion. endorsement—A written signature on the back of a
dysphagia—Difficulty in swallowing. check; required in order to receive payment.
Glossary 1037
endoscope—A lighted instrument used to examine the etiology—The study of the cause of a disease.
inside of the body. eupnea—Normal breathing pattern.
endosteum—Membrane lining the medullary canal of a eustachian tube—Tube that connects the middle ear
bone. and the pharynx, or throat.
enema—An injection of fluid into the large intestine eversion—Turning a body part outward.
through the rectum. exacerbation—Period of time during which the signs
enthusiasm—Intense interest or excitement. and symptoms of a chronic disease become more
entrepreneur—Individual who organizes, manages, severe.
and assumes the risk of a business. excretion—Process of eliminating waste products from
enunciate—To speak clearly, using correct pronuncia- the body.
tion. exocrine—Gland with a duct that produces a secretion.
enuresis—Bedwetting; loss of bladder control while exogenous—Infection or disease originating outside of
sleeping. or external to the body.
enzyme—A chemical substance that causes or increases expectorate—To spit; to expel mucus, phlegm, or spu-
the rate of a chemical reaction. tum from the throat or respiratory passages.
epidemic—An infectious disease that affects a large expiration—The expulsion of air from the lungs; breath-
number of people within a population, community, or ing out air.
region at the same time. extension—Increasing the angle between two parts;
epidemiology—The study of the history, cause, and straightening a limb.
spread of an infectious disease. external auditory canal—Passageway or tube extend-
epidermis—The outer layer of the skin. ing from the auricle of the ear to the tympanic mem-
epididymis—Tightly coiled tube in the scrotal sac; con- brane.
nects the testes with the vas or ductus deferens.
epigastric—Pertaining to the area of the abdomen above F
the stomach. facial surface—The tooth surface nearest the lips or
epiglottis—Leaf-shaped structure that closes over the cheek; includes the labial and buccal surfaces.
larynx during swallowing. facsimile—Machine that utilizes telephone lines to send
epilepsy—A chronic disease of the nervous system messages and/or documents from one location to
characterized by motor and sensory dysfunction, another location; a fax.
sometimes accompanied by convulsions and uncon- fainting—Partial or complete loss of consciousness
sciousness. caused by a temporary reduction in the supply of
epiphysis—The end or head at the extremity of a long blood to the brain.
bone. Fallopian tubes—Oviducts; in the female, passageway
epistaxis—Nosebleed. for the ova (egg) from the ovary to uterus.
epithelial tissue—Tissue that forms the skin and parts false imprisonment—Restraining an individual or
of the secreting glands, and that lines the body cavi- restricting an individual’s freedom.
ties. fanfold—Folding in accordion pleats; done with bed lin-
ergonomics—An applied science used to promote the ens.
safety and well-being of a person by adapting the envi- fascia—Fibrous membrane covering, supporting, and
ronment and using techniques to prevent injuries. separating muscles.
erythema—Redness of the skin. fasting blood sugar (FBS)—Blood test that measures
erythrocyte—Red blood cell (RBC). blood serum levels of glucose (sugar) after a person
erythrocyte count—Blood test that counts the number has had nothing by mouth for a period of time.
of red blood cells (normally 4–6 million per cubic mil- fat—Also called a lipid; nutrient that provides the most
limeter of blood). concentrated form of energy; highest-calorie energy
erythrocyte sedimentation rate (ESR)—Blood test nutrient; overweight.
that determines the rate at which red blood cells settle fat-restricted diet—Diet with limited amounts of fats,
out of the blood. or lipids.
esophagus—Tube that extends from the pharynx to the fax—See facsimile.
stomach. febrile—Pertaining to a fever, or elevated body tempera-
essential nutrients—Those elements in food required ture.
by the body for proper function. feces—Also called stool; waste material discharged from
esteem—Place a high value on; respect. the bowel.
ethics—Principles of right or good conduct. Federation Dentaire International (FDI) System—
ethnicity—Classification of people based on national Abbreviated means of identifying the teeth that uses a
origin and/or culture. two-digit code to identify the quadrant and tooth.
ethnocentric—Belief in the superiority of one’s own femur—Thigh bone of the leg; the longest and strongest
ethnic group. bone in the body.
1038 GLOSSARY
fertilization—Conception; impregnation of the ovum genital—Pertaining to the organs of reproduction.

by the sperm. genome—The total mass of genetic instruction humans
fetus—Unborn infant from the end of the third month of inherit from their parents.
pregnancy until birth. geriatrics, gerontology—The study of the aged or old
fever—Elevated body temperature, usually above 101°F, age and treatment of related diseases and conditions.
or 38.3°C, rectally. gingiva—The gums (tissues surrounding the teeth).
fibula—Outer and smaller bone of the lower leg. glaucoma—Eye disease characterized by increased
field—A specific data category within a computer data- intraocular pressure.
base, for example, the entry of an address in a patient glomerulus—Microscopic cluster of capillaries in Bow-
information database. man’s capsule of the nephron in the kidney.
filing—Arranging in order. glucose—The most common type of sugar in the body.
fire extinguisher—A device that can be used to put out glucose meter—Instrument used to measure blood-
fires. glucose (blood-sugar) level.
firewall—A software program or hardware device glycosuria—Presence of sugar in the urine.
designed to prevent unauthorized access to a com- goal—Desired result or purpose toward which one is
puter system. working.
first aid—Immediate care given to a victim of an injury Golgi apparatus—That structure in the cytoplasm of a
or illness to minimize the effects of the injury or ill- cell that produces, stores, and packages secretions for
ness. discharge from the cell.
fixed expenses—Those items in a budget that are set gonads—Sex glands, ovaries in the female and testes in
and usually do not change (for example, rent and car the male.
payments). goniometer—An instrument that measures the angle of
flatus—Air or gas in the intestines. a joint’s range of motion (ROM).
flexion—Decreasing the angle between two parts; bend- Gram’s stain—Technique of staining organisms to iden-
ing a limb. tify specific types of bacteria present.
fomite—Any substance or object that adheres to and graphic chart—Record used to record vital signs (for
transmits infectious material. example, temperature, pulse, and respirations) and
fontanel—Area between the cranial bones where the other information.
bones have not fused together; “soft spots” in the skull groin—Area between the abdomen and upper inner
of an infant. thigh.
foramina—A passage or opening; a hole in a bone gross income—Amount of pay earned before deduc-
through which blood vessels or nerves pass. tions are taken out.
Fowler’s position—The patient lies on the back with growth—Measurable physical changes that occur
the head elevated at one of several different angles. throughout a person’s life.
fracture—A break (usually, a break in a bone or tooth). gynecology—The study of diseases of women, espe-
frontal (coronal) plane—Imaginary line that separates cially those affecting the reproductive organs.
the body into a front section and a back section.
frostbite—Actual freezing of tissue fluid resulting in H
damage to the skin and underlying tissue. halitosis—Bad breath.
full liquid diet—Diet consisting of liquids and foods hantavirus—A virus spread by contact with rodents
that are liquid at body temperature. (rats and mice) or their excretions.
fungi—Group of simple, plantlike animals that live on hard copy—Computer term for a printed copy of infor-
dead organic matter (for example, yeast and molds). mation.
hard palate—Bony structure that forms the roof of the
G mouth.
gait—Method or manner of walking. hardware—Machine or physical components of a com-
gait belt—A belt placed around a patient’s waist to assist puter system (usually, the parts of the computer and
with transfer and/or ambulation. the peripherals).
gallbladder—Small sac near the liver; concentrates and heading—That section of a letter containing the address
stores bile. of the person sending the letter and the date of writ-
gastric—Pertaining to the stomach. ing.
gastrostomy—Surgical opening through the abdominal Health Insurance Portability and Accountability
wall into the stomach; used for inserting a feeding Act (HIPAA)—Set of federal regulations adopted to
tube. protect the confidentiality of patient information and
generic name—Chemical name of a drug; name not the ability to retain health insurance coverage.
protected by a trademark. heart attack—See myocardial infarction.
genes—The structures on chromosomes that carry heat cramp—Muscle pain and spasm resulting from
inherited characteristics. exposure to heat and inadequate fluid and salt intake.
Glossary 1039
heat exhaustion—Condition resulting from exposure hospital—Institution that provides medical or surgical
to heat and excessive loss of fluid through sweating. care and treatment for the sick or injured.
heat stroke—Medical emergency caused by prolonged humerus—Long bone of the upper arm.
exposure to heat, resulting in high body temperature hydrocollator packs—Gel-filled packs that are warmed
and failure of sweat glands. in a water bath to provide a moist heat application.
helminths—A parasitic worm (for example, a tapeworm hygiene—Principles for health preservation and disease
or leech). prevention.
hematemesis—Vomiting of blood. hyperglycemia—Presence of sugar in the blood; high
hematocrit—Blood test that measures the percentage blood sugar.
of red blood cells per a given unit of blood. hyperopia—Farsightedness; defect in near vision.
hematology—The study of blood and blood diseases. hyperpnea—An increased respiratory rate.
hematoma—A localized mass of blood. hypertension—High blood pressure.
hematopoiesis—Formation of blood cells. hyperthermia—Condition that occurs when body tem-
hematuria—Blood in the urine. perature exceeds 104°F, or 40°C, rectally.
hemiplegia—Paralysis on one side of the body. hypoglycemia—Low blood sugar.
hemodialysis—Mechanical method of circulating blood hypotension—Low blood pressure.
through semipermeable membranes to remove body hypothalamus—That structure in the diencephalon of
wastes; procedure used for kidney failure. the brain that regulates and controls many body func-
hemoglobin—The iron-containing protein of the red tions.
blood cells; serves to carry oxygen from the lungs to hypothermia—Condition in which body temperature is
the tissues. below normal, usually below 95°F (35°C) and often in
hemolysis—Disintegration of red blood cells, causing the range of 78–95°F (26–35°C).
cells to dissolve or go into solution. hypothermia blanket—Special blanket containing
hemoptysis—Spitting up blood; blood-stained sputum. coils filled with a cooling solution; used to reduce high
hemorrhage—Excessive loss of blood; bleeding. body temperature.
hemorrhoids—Varicose veins of the anal canal or anus. hypoxia—Without oxygen; a deficiency of oxygen.
hemostat—Instrument used to compress (clamp) blood
vessels to stop bleeding. I
heparin—A substance formed in the liver to prevent the ice bag/collar—Plastic or rubber device filled with ice
clotting of blood; an anticoagulant. to provide dry-cold application.
hepatitis—Inflammation of the liver. idiopathic—Without recognizable cause; condition that
high-fiber diet—Diet containing large amounts of fiber, is self-originating.
or indigestible food. ileostomy—A surgical opening connecting the ileum
high-protein diet—Diet containing large amounts of (small intestine) and the abdominal wall.
protein-rich foods. ileum—Final section of small intestine; connects the
high-velocity oral evacuator—Dental handpiece jejunum and large intestine.
used to remove particles and large amounts of liquid immunity—Condition of being protected against a par-
from the oral cavity. ticular disease.
HIPAA—See Health Insurance Portability and impaction—A large, hard mass of fecal material lodged
Accountability Act. in the intestine or rectum; a tooth that does not erupt
histology—Study of tissue. into the mouth.
holistic health care—Care that promotes physical, impression—Negative reproduction of a tooth or dental
emotional, social, intellectual, and spiritual well- arch.
being. incisal surface—The cutting or biting surface of ante-
home health care—Any type of health care provided in rior teeth.
a patient’s home environment. incision—Cut or wound of body tissue caused by a sharp
homeostasis—A constant state of natural balance object; a surgical cut.
within the body. incisors—Teeth located in the front and center of the
honesty—Truthfulness; integrity. mouth; used to cut food.
horizontal recumbent position—See supine posi- income—Total amount of money received in a given
tion. period (usually a year); salary is usually the main
hormone—Chemical substance secreted by an organ or source.
gland. incontinent—Unable to voluntarily control urination or
HOSA—Health Occupations Students of America, a defecation.
national organization for students enrolled in health index—To put names in proper order for filing pur-
occupations programs. poses.
hospice—Program designed to provide care for the ter- infancy—Period of development from birth to 1 year of
minally ill while allowing them to die with dignity. age.
1040 GLOSSARY
infarction—Area of tissue that is necrotic (dead) after invasive—Pertains to a test or procedure that involves
the cessation of a blood supply; death of tissue. penetrating or entering the body.
infection—Invasion by organisms; contamination by inversion—Turning a body part inward.
disease-producing organisms, or pathogens. involuntary—Independent action not controlled by
inferior—Below; under. choice or desire.
inflammation—Tissue reaction to injury characterized iris—Colored portion of the eye; composed of muscular,
by heat, redness, swelling, and pain. or contractile, tissue that regulates the size of the
informed consent—Permission granted voluntarily by pupil.
a person who is of sound mind and aware of all factors ischemia—Inadequate blood flow to the body tissues
involved. caused by an obstruction in circulation.
ingestion—Taking food, fluids, or medications into the isolation—Method or technique of caring for persons
body through the mouth. who have communicable diseases.
inguinal—Pertaining to the region of the body where
the thighs join the trunk; the groin. J
inhalation—Breathing in. jackknife (proctologic) position—The patient lies on
initiative—Ability to begin or follow through with a plan the abdomen with both the head and legs inclined
or task; determination. downward and the rectal area elevated.
input—Computer term for information that is entered jaundice—Yellow discoloration of the skin and eyes, fre-
into a computer. quently caused by liver or gallbladder disease.
inquiry—Search for information. jejunum—The middle section of the small intestine;
insertion—End or area of a muscle that moves when the connects the duodenum and ileum.
muscle contracts. job interview—A face-to-face meeting or conversation
inside address—That section of a letter that contains between an employer and an applicant for a job.
the name and address of the person or firm to whom joint—An articulation, or area where two bones meet or
the letter is being sent. join.
inspiration—Breathing in; taking air into the lungs.
insulin—A hormone secreted by the islets of Langerhans K
in the pancreas; essential for the metabolism of glu- kcal-controlled diet—Diet containing low-calorie
cose. foods; frequently prescribed for weight loss.
insulin shock—Condition that occurs in individuals ketone—Chemical compound produced during an
with diabetes when there is an excess amount of insu- increased metabolism of fat.
lin and a low level of glucose (sugar) in the blood. ketonuria—Presence of ketones in the urine.
insurance form—A form used to apply for payment by kidney—Bean-shaped organ that excretes urine; located
an insurance company. high and in back of the abdominal cavity.
intake and output (I&O)—A record that notes all fluids kilocalorie—Unit used to measure the energy value of
taken in or eliminated by a person in a given period of food.
time. kilojoule—Metric unit used to measure the energy value
integrative health care—A form of health care that of food.
uses both mainstream medical treatments and com- knee–chest position—The patient rests his or her body
plementary and alternative therapies to treat a weight on the knees and chest; used for sigmoido-
patient. scopic and rectal examinations.
integumentary—Pertaining to the skin or a covering.
interactive video—The color, sound, and motion of L
video technology integrated with computer-assisted labia majora—Two large folds of adipose tissue lying
instruction to create a new technology. on each side of the vulva in the female; hairy outer
intercostal—Pertaining to the space between the ribs lips.
(costae). labia minora—Two folds of membrane lying inside the
Internet—Worldwide computer network. labia majora; hairless inner lips.
interproximal space—The area between two adjoin- labial surface—Crown surface of the anterior teeth
ing teeth. that lies next to the lips; facial surface of the anterior
intestine—That portion of the alimentary canal from teeth.
the stomach to the rectum and anus. laboratory—A room or building where scientific tests,
intradermal—Inserted or put into the skin. research, experiments, or learning takes place.
intramuscular—Injected or put into a muscle. laceration—Wound or injury with jagged, irregular
intravenous—Injected or put into a vein. edges.
intubate—To insert a tube. lacrimal—Pertaining to tears; glands that secrete and
invasion of privacy—Revealing personal information expel tears.
about an individual without his or her consent. lactation—Process of secreting milk.
Glossary 1041
lacteal—Specialized lymphatic capillary that picks up liver—Largest gland in the body; located in the upper
digested fats or lipids in the small intestine and trans- right quadrant of the abdomen; two of its main func-
ports them to the thoracic duct. tions are excreting bile and storing glycogen.
lancet—Sharp, pointed instrument used to pierce the living will—A legal document stating a person’s desires
skin to obtain blood. on what measures should or should not be taken to
laryngeal mirror—Instrument with a mirror, used to prolong life when his or her condition is terminal.
examine larynx. low-cholesterol diet—Diet that restricts foods high in
larynx—Voice box, located between the pharynx and saturated fat.
trachea. low-protein diet—Diet that limits foods high in pro-
late adulthood—Period of development beginning at tein.
65 years of age and ending at death. low-residue diet—Diet that limits foods containing
late childhood—Period of development from 6 to 12 large amounts of residue, or indigestibles.
years of age. low-speed handpiece—Slower handpiece in dental
lateral—Pertaining to the side. units; used to remove caries and for fine finishing work.
lead—An angle or view of the heart that is recorded in an lung—Organ of respiration located in the thoracic cav-
electrocardiogram. ity.
leadership—Ability to lead, guide, and direct others. lymph—Fluid formed in body tissues and circulated in
ledger card—A card or record that shows a financial the lymphatic vessels.
account of money charged, received, or paid out. lymph node—A round body of lymph tissue that filters
left lateral position—See Sims’ position. lymph.
legal—Authorized or based on law. lymphatic duct—Short tube that drains purified lymph
legal disability—A condition in which a person does from the right sides of the head and neck and the right
not have legal capacity and is therefore unable to enter arm.
into a legal agreement (for example, as is the case with lymphatic vessels—Thin-walled vessels that carry
a minor). lymph from tissues.
lens—Crystalline structure suspended behind the pupil lysosomes—Those structures in the cytoplasm of a cell
of the eye; refracts or bends light rays onto the retina; that contain digestive enzymes to digest and destroy
also, the magnifying glass in a microscope. old cells, bacteria, and foreign matter.
lethargy—Abnormal drowsiness or sluggishness; state
of indifference or stupor. M
letterhead—Preprinted heading at the top of paper used macule—A discolored but neither raised nor depressed
for written correspondence. spot or area on the skin.
leukocyte—White blood cell (WBC). magnetic resonance imaging (MRI)—Process that
leukocyte count—Blood test that counts the total num- uses a computer and magnetic forces, instead of
ber of white blood cells (normally 5,000–9,000 cells per X-rays, to visualize internal organs.
cubic millimeter of blood). mainframe computer—Largest type of computer;
liability—A legal or financial responsibility. many users can access this computer at the same
libel—False written statement that causes a person ridi- time.
cule or contempt or causes damage to the person’s malignant—Harmful or dangerous; likely to spread and
reputation. cause destruction and death (for example, cancer).
licensure—Process by which a government agency malnutrition—Poor nutrition; without adequate food
authorizes individuals to work in a given occupa- and nutrients.
tion. malpractice—Providing improper or unprofessional
life stages—Stages of growth and development experi- treatment or care that results in injury to another
enced by an individual from birth to death. person.
ligament—Fibrous tissue that connects bone to bone. mammogram—X-ray examination of the breasts.
light diet—Also called a convalescent diet; diet that con- managed care—A health care delivery system designed
tains easy-to-digest foods. to reduce the cost of health care while providing access
line angle—Area on crown surfaces of a tooth formed by to care through designated providers.
a line drawn between two surfaces. mandible—Horseshoe-shaped bone that forms the
liner—Dental material that covers or lines exposed tooth lower jaw; only movable bone of the skull.
tissue, usually in the form of a varnish. master’s degree—Degree awarded by a college or uni-
lingual surface—The crown surface of teeth that is next versity after completion of one or more years of pre-
to the tongue. scribed study beyond a bachelor’s degree.
listen—To pay attention, make an effort to hear. mastication—The process of chewing with the teeth.
lithotomy position—The patient lies on the back Material Safety Data Sheets (MSDSs)—Information
with the feet in stirrups and knees flexed and sepa- sheets that must be provided by the manufacturer for
rated. all hazardous products.
1042 GLOSSARY
matriarchal—Social organization in which the mother midbrain—That portion of the brain that connects the
or oldest woman is the authority figure. pons and cerebellum; relay center for impulses.
maxilla—Upper jawbone; two bones fused or joined middle adulthood—Period of development from 40–65
together. years of age.
meatus—External opening of a tube (for example, the midsagittal—An imaginary line drawn down the mid-
urinary meatus). line of the body to divide the body into a right side and
mechanical lift—Special device used to move or trans- a left side.
fer a patient. midstream (clean-catch) specimen—Urine speci-
medial—Pertaining to the middle or midline. men in which urination is begun before catching the
Medicaid—Government program that provides medical specimen in the specimen cup.
care for people whose incomes are below a certain minerals—Inorganic substances essential to life.
level. mitered corner—Special folding technique used to
medical history—A record that shows all diseases, ill- secure linen on a bed.
ness, and surgeries that a patient has had. mitochondria—Those structures in a cell that provide
medical record—Also called a patient chart; written energy and are involved in the metabolism of the cell.
record of a patient’s diagnosis, care, treatment, test mitosis—Process of asexual reproduction by which cells
results, and prognosis. divide into two identical cells.
Medicare—Government program that provides medical mitral valve—Flap or cusp between the left atrium and
care for elderly and/or disabled individuals. left ventricle in the heart.
medication—Drug used to treat a disease or condition. model—Also called a cast; a positive reproduction of the
Medigap policy—An insurance plan that serves as sup- dental arches or teeth in plaster or similar materials.
plemental insurance to Medicare; usually pays deduct- modified block—Letter-writing format in which all
ible for Medicare and co-payments of care. parts of the letter start at the left margin except the
medulla—Inner, or central, portion of an organ. heading, complimentary close, signature, and title,
medulla oblongata—The lower part of the brainstem; which start at the center line.
controls vital processes such as respiration and heart- moist cold—An application that provides cold tempera-
beat. ture and is wet against the skin.
medullary canal—Inner, or central, portion of a long moist heat—An application that provides warm tem-
bone. perature and is wet against the skin.
meiosis—The process of cell division that occurs in molars—Teeth in the back of the mouth; largest and
gametes, or sex cells (ovum and spermatozoa). strongest teeth; used to grind food.
melanin—Brownish black pigment found in the skin, motivated—Stimulated into action; incentive to act.
hair, and eyes. mouth—Oral cavity; opening to the digestive tract, or
memorandum—A short, written statement or mes- alimentary canal.
sage. mucus—Thick, sticky fluid secreted by mucous mem-
meninges—Membranes that cover the brain and spinal branes.
cord. muscle tissue—Body tissue composed of fibers that
menopause—Permanent cessation of menstruation. produce movement.
mental—Pertaining to the mind. muscle tone—State of partial muscle contraction pro-
mesial surface—The side surface of teeth that is toward viding a state of readiness to act.
the midline of the mouth. myocardial infarction—Heart attack; a reduction in
metabolism—The use of food nutrients by the body to the supply of blood to the heart resulting in damage to
produce energy. the muscle of the heart.
metacarpal—Bone of the hand between the wrist and myocardium—Muscle layer of the heart.
each finger. myopia—Nearsightedness; defect in distant vision.
metastasis—The spread of tumor or cancer cells from myth—A false belief; an established belief with no basis.
the site of origin.
metatarsal—Bone of the foot between the instep and N
each toe. nasal cavity—Space between the cranium and the roof
microbiology—Branch of biology dealing with the of the mouth.
study of microscopic organisms. nasal septum—Bony and cartilaginous partition that
microcomputer—Desktop or personal computer found separates the nasal cavity into two sections.
in the home or office. nasogastric tube—A tube that is inserted through the
microorganism—Small, living plant or animal not vis- nose and goes down the esophagus and into the stom-
ible to the naked eye; a microbe. ach.
microscope—Instrument used to magnify or enlarge nausea—A feeling of discomfort in the region of the
objects for viewing. stomach accompanied by the tendency to vomit.
micturate—Another word for urinate; to expel urine. necrosis—Death of tissue.
Glossary 1043
need—Lack of something required or desired; urgent odontology—Study of the anatomy, growth, and dis-
want or desire. eases of the teeth.
needle holder—Instrument used to hold or support a olfactory—Pertaining to the sense of smell.
needle while sutures (stitches) are being inserted. oliguria—Decreased or less-than-normal amounts of
negligence—Failure to give care that is normally urine secretion.
expected, resulting in injury to another person. ombudsman—Specially trained individual who acts
neonate—Newborn infant. as an advocate for others to improve care or condi-
neoplasm—New growth or tumor. tions.
nephritis—Inflammation of the kidney. Omnibus Budget Reconciliation Act (OBRA)—Fed-
nephron—Structural and functional unit of the kidney. eral law that regulates the education and testing of
nerve—Group of nerve tissues that conducts impulses. nursing assistants.
nerve tissue—Body tissue that conducts or transmits oncology—The branch of medicine dealing with tumors
impulses throughout the body. or abnormal growths (for example, cancer).
net income—Amount of pay received for hours worked open bed—A bed with the top sheets fanfolded to the
after all deductions have been taken out; take-home bottom.
pay. ophthalmologist—A medical doctor who specializes in
network—Connection of two or more computers to diseases of the eye.
share data and hardware. ophthalmology—The study of the eye and diseases and
neurology—The study of the nervous system. disorders affecting the eye.
neuron—Nerve cell. ophthalmoscope—An instrument used to examine the
nocturia—Excessive urination at night. eye.
noninvasive—Pertaining to a test or procedure that opportunistic infection—An infection that occurs
does not require penetration or entrance into the when the body’s immune system cannot defend itself
body. from pathogens normally found in the environment.
nonpathogen—A microorganism that is not capable of optician—An individual who makes or sells lenses, eye-
causing a disease. glasses, and other optical supplies.
nonverbal—Without words or speech. optometrist—A licensed, nonmedical practitioner who
nose—The projection in the center of the face; the organ specializes in the diagnosis and treatment of vision
for smelling and breathing. defects.
nosocomial—Pertaining to or originating in a health oral—Pertaining to the mouth.
care facility such as a hospital. oral cavity—The mouth.
nucleolus—The spherical body in the nucleus of a cell oral hygiene—Care of the mouth and teeth.
that is important in reproduction of the cell. oral-evacuation system—Special machine that uses
nucleus—The structure in a cell that controls cell activi- water to form a suction or vacuum system to remove
ties such as growth, metabolism, and reproduction. liquids and particles from the oral cavity.
nutrition—All body processes related to food; the body’s organ—Body part made of tissues that have joined
use of food for growth, development, and health. together to perform a special function.
nutritional status—The state of one’s nutrition. organ of Corti—Structure in the cochlea of the ear;
organ of hearing.
O organelles—Structures in the cytoplasm of a cell,
obese—Overweight. including the nucleus, mitochondria, ribosomes, lyso-
objective observation—An observation about a somes, and Golgi apparatus.
patient that is visible, palpable, or measurable; com- origin—End or area of a muscle that remains stationary
monly called a sign. when the muscle contracts.
observation—To look at, watch, perceive, or notice. originator—The person who writes a check to issue
obstetrics—The branch of medicine dealing with preg- payment.
nancy and childbirth. orthodontics—The branch of dentistry dealing with
occlusal surface—The chewing or biting surface of prevention and correction of irregularities of the align-
posterior teeth. ment of teeth.
occult—Hidden, concealed, not visible (for example, an orthopedics—The branch of medicine/surgery dealing
internal [occult] hemorrhage). with the treatment of diseases and deformities of the
occult blood—Blood that is hidden; also, a test done on bones, muscles, and joints.
stool to check for the presence of blood. orthopnea—Severe dyspnea in which breathing is very
occupational therapy—Treatment directed at prepar- difficult in any position other than sitting erect or
ing a person requiring rehabilitation for a trade or for standing.
return to the activities of daily living. orthotist—An individual skilled in straightening or cor-
occupied bed—A bed that is made while the patient is recting deformities by the use of orthopedic appli-
in bed. ances (for example, braces or special splints).
1044 GLOSSARY
os coxae—The hipbone; formed by the union of the patella—The kneecap.

ilium, ischium, and pubis. pathogen—Disease-producing organisms.
ossicles—Small bones, especially the three bones of the pathology—The study of the cause or nature of a dis-
middle ear that amplify and transmit sound waves. ease.
osteopathy—A field of medicine and treatment based pathophysiology—Study of how disease occurs and the
on manipulation, especially of the bones, to treat dis- responses of living organisms to disease processes.
ease. patience—Ability to wait, persevere; capacity for calm
osteoporosis—Condition in which bones become endurance.
porous and brittle because of lack or loss of calcium, patients’ rights—Factors of care that all patients can
phosphorus, and other minerals. expect to receive.
ostomy—A surgically created opening into a body part. patriarchal—Social organization in which the father or
otoscope—An instrument used to examine the ear. oldest male is the authority figure.
output—Computer term for processed information, or patriotism—Love and devotion to one’s country.
the final product obtained from the computer; also, payee—Person receiving payment.
total amount of liquid expelled from the body. pediatrics—The branch of medicine dealing with care
ovary—Endocrine gland or gonad that produces hor- and treatment of diseases and disorders of children.
mones and the female sex cell, or ovum. pedodontics—The branch of dentistry dealing with
treatment of teeth and oral conditions of children.
P pegboard system—Method of maintaining financial
palate—Structure that separates the oral and nasal cavi- accounts and records in an office.
ties; roof of the mouth. pelvic—Pertaining to the pelvis area below the abdomi-
palliative—Measures taken to treat symptoms and/or nal region and near the sacrum and hip bones.
pain even though it will not cure a disease; comfort penis—External sex organ of the male.
measures. percussion—Process of tapping various body parts dur-
pallor—Paleness; lack of color. ing an examination.
palpation—The act of using the hands to feel body parts percussion (reflex) hammer—Instrument used to
during an examination. check reflexes.
pancreas—Gland that is dorsal to the stomach; secretes periapical—Around the apex of a root of a tooth; dental
insulin and digestive juices. X-ray that shows the entire tooth and surrounding
pandemic—An infectious disease that affects many area.
people over a wide geographic area; a worldwide epi- pericardium—Membrane sac that covers the outside of
demic. the heart.
panoramic—Dental radiograph that shows the entire perineum—Region between the vagina and anus in the
dental arch, or all of the teeth and related structures, female and between the scrotum and anus in the male.
on one film. periodontal ligament—Dense fibers of connective tis-
Papanicolaou test—Also called a Pap test; a test to clas- sue that attach to the cementum of a tooth and the
sify abnormal cells obtained from the vagina or cer- alveolus to support or suspend the tooth in its socket.
vix. periodontics—The branch of dentistry dealing with the
papule—Solid, elevated spot or area on the skin. treatment of the gingiva (gum) and periodontium
paraffin wax treatment—Heated mixture of paraffin (supporting tissues) surrounding the teeth.
and mineral oil; used to provide a moist heat applica- periodontium—Structures that surround and support
tion. the teeth.
paralysis—Loss or impairment of the ability to feel or periosteum—Fibrous membrane that covers the bones
move parts of the body. except at joint areas.
paraplegia—Paralysis of the lower half of the body. peripheral—That part of the nervous system apart from
parasite—Organism that lives on or within another liv- the brain and spinal cord; also, a device connected to a
ing organism. computer.
parasympathetic—A division of the autonomic ner- peristalsis—Rhythmic, wavelike motion of involuntary
vous system. muscles.
parathyroid—One of four small glands located on the peritoneal—Pertaining to the body cavity containing
thyroid gland; regulates calcium and phosphorus the liver, stomach, intestines, urinary bladder, and
metabolism. internal reproductive organs.
parenteral—Other than by mouth. permanent (succedaneous) teeth—The 32 teeth that
paresis—Weakness and/or paralysis of an extremity. make up the second, or permanent, set of teeth.
partial bath—Bath in which only certain body parts are personal hygiene—Care of the body including bathing,
bathed or in which the health care provider bathes hair and nail care, shaving, and oral hygiene.
those parts of the body that the patient is unable to personal protective equipment (PPE)—Protective
bathe. barriers such as a mask, gown, gloves, and protective
Glossary 1045
eyewear that help protect a person from contact with detects a radioactive substance injected into a
infectious material. patient.
perspiration—The secretion of sweat. posterior—Toward the back; behind.
pH—A scale of 0–14 used to measure the degree of acidity posterior teeth—Teeth toward the back of the oral cav-
or alkalinity of a substance, with 7 being neutral. ity, including the bicuspids and molars.
phalanges—Bones of the fingers and toes. postmortem care—Care given to the body immediately
pharmacology—The study of drugs. after death.
pharynx—The throat. postoperative—After surgery.
phlebitis—Inflammation of a vein. postpartum—Following delivery of a baby.
phlebotomist—Also called a venipuncture technician; Power of Attorney (POA)—A legal document authoriz-
individual who collects blood and prepares it for tests. ing a person to act as another person’s legal represen-
physiatrist—Medical doctor specializing in rehabilita- tative or agent.
tion. prefix—An affix attached to the beginning of a word.
physical—Of or pertaining to the body. prejudice—Strong feeling or belief about a person or
physical therapy—Treatment by physical means, such subject that is formed without reviewing facts or infor-
as heat, cold, water, massage, or electricity. mation.
Physicians’ Desk Reference (PDR)—Reference book prenatal—Before birth.
that contains essential information on medications. preoperative—Before surgery.
physiological needs—Basic physical or biological pressure (decubitus) ulcer—A pressure sore; a bed-
needs required by every human being to sustain life. sore.
physiology—The study of the processes or functions of primary (deciduous) teeth—Also called deciduous
living organisms. teeth; the first set of 20 teeth.
pineal—Glandlike structure in the brain. privileged communications—All personal informa-
pinna—Also called the auricle; external portion of the ear. tion given to health personnel by a patient; must be
pituitary—Small, rounded endocrine gland at the base kept confidential.
of the brain; regulates function of other endocrine proctoscope—Instrument used to examine the rectum.
glands and body processes. prognosis—Prediction regarding the probable outcome
placenta—Temporary endocrine gland created during of a disease.
pregnancy to provide nourishment for the fetus; the projection—Defense mechanism in which an individ-
afterbirth. ual places the blame for his or her actions on someone
plane—Flat or relatively smooth surface; an imaginary else or circumstances.
line drawn through the body at various parts to sepa- pronation—Turning a body part downward; turning
rate the body into sections. “palm down.”
plaque—Thin, tenacious, filmlike deposit that adheres prone position—The patient lies on the abdomen, with
(sticks) to the teeth and can lead to decay; made of the legs together and the face turned to the side.
protein and microorganisms. prophylactic—Preventive; agent that prevents
plasma—Liquid portion of the blood. disease.
platelet—See thrombocyte. prophylaxis angle—Dental handpiece attachment that
pleura—A serous membrane that covers the lungs and holds polishing cups, disks, and brushes used to clean
lines the thoracic cavity. the teeth or polish restorations.
podiatrist—An individual who specializes in the diag- prostate gland—In the male, gland near the urethra;
nosis and treatment of diseases and disorders of the contracts during ejaculation to prevent urine from
feet. leaving the bladder.
point angle—Area on the crown surface of a tooth that prosthesis—An artificial part that replaces a natural
is formed when three surfaces meet. part (for example, dentures or a limb).
poisoning—Condition that occurs when contact is prosthodontics—The branch of dentistry dealing with
made with any chemical substance that causes injury, the construction of artificial appliances for the
illness, or death. mouth.
polycythemia—Excess number of red blood cells. protective isolation—See reverse isolation.
polydipsia—Excessive thirst. protein—One of six essential nutrients needed for
polyphagia—Excessive ingestion of food. growth and repair of tissues.
polyuria—Increased production and discharge of urine; protoplasm—Thick, viscous substance that is the phys-
excessive urination. ical basis of all living things.
pons—That portion of the brainstem that connects the protozoa—Microscopic, one-celled animals often found
medulla oblongata and cerebellum to the upper por- in decayed materials and contaminated water.
tions of the brain. proximal—Closest to the point of attachment or area of
positron emission tomography (PET)—Computer- reference.
ized body scanning technique in which the computer pruritus—Itching.
1046 GLOSSARY
psychiatry—The branch of medicine dealing with the rate—Number per minute, as with pulse and respiration
diagnosis, treatment, and prevention of mental illness. counts.
psychology—The study of mental processes and their rationalization—Defense mechanism involving the
effects on behavior. use of a reasonable or acceptable excuse as explana-
psychosomatic—Pertaining to the relationship between tion for behavior.
the mind or emotions and the body. read only memory (ROM)—Nonerasable, permanent
puberty—Period of growth and development during form of computer memory built into a computer to
which secondary sexual characteristics begin to control many of the computer’s internal operations.
develop. reagent strip—Special test strip containing chemical
pulmonary—Pertaining to the lungs. substances that react to the presence of certain sub-
pulmonary valve—Flap or cusp between the right ven- stances in the urine or blood.
tricle of the heart and the pulmonary artery. reality orientation—Activities to help promote aware-
pulp—Soft tissue in the innermost area of a tooth and ness of time, place, and person.
made of nerves and blood vessels held in place by con- recall—To call back; letter or notice that reminds a
nective tissue. patient to return for periodic treatment or examina-
pulse—Pressure of the blood felt against the wall of an tion.
artery as the heart contracts or beats. receipt—Written record that money or goods has been
pulse deficit—The difference between the rate of an received.
apical pulse and the rate of a radial pulse. rectal, rectum—Pertaining to or the lower part of the
pulse oximeter—A device that measures the oxygen large intestine, the temporary storage area for indi-
level in arterial blood. gestibles.
pulse pressure—The difference between systolic and rectal tube—Tube inserted into the rectum to aid in the
diastolic blood pressure. expulsion of flatus (gas).
puncture wound—Injury caused by a pointed object red blood cell—See erythrocyte.
such as a needle or nail. red marrow—Soft tissue in the epiphyses of long
pupil—Opening or hole in the center of the iris of the bones.
eye; allows light to enter the eye. reference initials—Initials placed at the bottom of a
pustule—Small, elevated, pus- or lymph-filled area of letter to indicate the writer and/or preparer.
the skin. refractometer—An instrument used to measure the
pyrexia—Fever. specific gravity of urine.
pyuria—Pus in the urine. registration—Process whereby a regulatory body in a
given health care area administers examinations and/
Q or maintains a list of qualified personnel.
quadriplegia—Paralysis below the neck; paralysis of rehabilitation—The restoration to useful life through
arms and legs. therapy and education.
religion—Spiritual beliefs and practices of an individual.
R remission—Period of time during which the signs and
race—Classification of people based on physical or bio- symptoms of a chronic disease are less severe or not
logical characteristics. present.
radial deviation—Moving toward the thumb side of the repression—Defense mechanism involving the transfer
hand. of painful or unacceptable ideas, feelings, or thoughts
radiograph—X-ray; an image produced by radiation. into the subconscious.
radiology—The branch of medicine dealing with X-rays resident—An individual who lives in a long-term care
and radioactive substances. facility.
radiolucent—Transparent to X-rays; permitting the resistant—Able to oppose; organisms that remain unaf-
passage of X-rays or other forms of radiation. fected by harmful substances in the environment.
radiopaque—Not transparent to X-rays; not permitting respiration—The process of taking in oxygen (inspira-
the passage of X-rays or other forms of radiation. tion) and expelling carbon dioxide (expiration) by way
radius—Long bone of the forearm, between the wrist of the lungs and air passages.
and elbow. responsibility—Being held accountable for actions or
rale—Bubbling or noisy sound caused by fluid or mucus behaviors; willing to meet obligations.
in the air passages. restoration—Process of replacing a diseased portion of
random access memory (RAM)—Form of computer a tooth or a lost tooth by artificial means, including fill-
memory known as read/write memory because data ing materials, crowns, bridges, or dentures.
can be stored or retrieved from it. restraints—Protective devices that limit or restrict
range of motion (ROM)—The full range of movement movement.
of a muscle or joint; exercises designed to move each résumé—A summary of a person’s work history and
joint and muscle through its full range of movement. experience, submitted when applying for a job.
Glossary 1047
retina—The sensory membrane that lines the eye and is male individual; secretes thick, viscous fluid for
the immediate instrument of vision. semen.
retractor—Instrument used to hold or draw back the senile lentigines—Dark-yellow or brown spots that
lips or sides of a wound or incision. develop on the skin as aging occurs.
reverse isolation—Technique used to provide care to senility—Feebleness of body or mind caused by aging.
patients requiring protection from organisms in the sensitive—Susceptible to a substance; organisms that
environment. are affected by an antibiotic in a culture and sensitivity
rheostat—Foot control in dental units; used to operate study.
handpieces. sensitivity—Ability to recognize and appreciate the per-
rhythm—Referring to regularity; regular or irregular. sonal characteristics of others.
ribs—Also called costae; 12 pairs of narrow, curved bones sepsis—Presence of pus-forming pathogens and their
that surround the thoracic cavity. toxins in the blood.
rickettsiae—Parasitic microorganisms that live on other septum—Membranous wall that divides two cavities.
living organisms. serrated—Notched; toothed.
root—The anatomic portion of a tooth that is below the sharps container—A puncture-resistant container for
gingiva (gums); helps hold the tooth in the mouth. disposal of needles, syringes, and other sharp objects
rotation—Movement around a central axis; a turning. contaminated by blood or body fluids.
rubber base—Dental impression material that is elastic shock—Clinical condition characterized by various
and rubbery in nature. symptoms and resulting in an inadequate supply of
blood and oxygen to body organs, especially the brain
S and heart.
safety standards—Set of rules designed to protect both sigmoidoscope—Instrument used to examine the sig-
the patient and the health care worker. moid, or S-shaped, section of the large intestine.
saliva ejector—Handpiece in dental units that provides sign—Objective evidence of disease; something that is
a constant, low-volume suction to remove saliva and seen.
fluids from the mouth. signature—A person’s name written by that person.
salivary glands—Glands of the mouth that produce Sims’ position—The patient lies on his or her left side
saliva, a digestive secretion. with the right leg bent up near the abdomen.
salutation—A greeting; the greeting in a letter (for sinus—Cavity or air space in a bone.
example, “Dear”). sitz bath—Special bath given to apply moist heat to the
sarcoma—Tumor of connective tissue; frequently malig- genital or rectal area.
nant. skeleton—The bony structure of the body.
satisfaction—Fulfillment or gratification of a desire or skill—Expertness, dexterity; an art, trade, or technique.
need. skin puncture—A small puncture made in the skin to
scalpel—Instrument with a knife blade used to incise obtain capillary blood.
(cut) skin and tissue. slander—Spoken comment that causes a person
scapula—Shoulder blade or bone. ridicule or contempt or damages the person’s reputa-
sclera—White outer coat of the eye. tion.
screen—To evaluate; to determine the purpose of tele- small intestine—That section of the intestine that is
phone calls so they can be referred to the correct between the stomach and large intestine; site of most
person. absorption of nutrients.
scrotum—Double pouch containing the testes and epi- smear—Material spread thinly on a slide for microscopic
didymis in the male individual. examination.
search engine—Computer program designed to locate Snellen charts—Special charts that use letters or sym-
specific information on the Internet. bols in calibrated heights to check visual acuity.
sebaceous gland—Oil-secreting gland of the skin. social—Pertaining to relationships with others.
secretion—Substance produced and expelled by a gland sodium hypochlorite—Household bleach.
or other body part. sodium-restricted diet—Special diet containing low
seizure—A convulsion; involuntary contraction of mus- or limited amounts of sodium (salt).
cles. soft diet—Special diet containing only foods that are soft
self-actualization—Achieving one’s full potential. in texture.
self-esteem—Satisfaction with oneself. soft palate—Tissue at the back of the roof of the mouth;
self-motivation—Ability to begin or to follow through separates the mouth from the nasopharynx.
with a task without the assistance of others. software—Programs or instructions that allow computer
semicircular canals—Structures of the inner ear that hardware to function intelligently.
are involved in maintaining balance and equilibrium. specific gravity—Weight or mass of a substance com-
seminal vesicle—One of two saclike structures behind pared with an equal amount of another substance that
the bladder and connected to the vas deferens in the is used as a standard.
1048 GLOSSARY
speculum—Instrument used to dilate, or enlarge, an subjective observation—An observation about a

opening or passage in the body for examination pur- patient that is felt by the patient but cannot be seen,
poses. palpated, or measured; commonly called a symptom.
sphygmomanometer—Instrument calibrated for mea- sublingual—Under the tongue.
suring blood pressure in millimeters of mercury (mm succedaneous teeth—The 32 teeth that make up the
Hg). second set of teeth; also called permanent or second-
spinal—Pertaining to the vertebral column or spinal cord. ary teeth.
spinal cord—A column of nervous tissue extending sudoriferous gland—Sweat-secreting gland of the
from the medulla oblongata of the brain to the second skin.
lumbar vertebra in the vertebral column. suffix—An affix attached to the end of a word.
spirituality—Individualized and personal set of beliefs suicide—Killing oneself.
and practices that evolve and change throughout an superior—Above, on top of, or higher than.
individual’s life. supination—Turning a body part upward; turning
spleen—Ductless gland below the diaphragm and in the “palm up.”
upper-left quadrant of the abdomen; serves to form, supine position—The patient lies flat on the back, face
store, and filter blood. upward.
splinter forceps—Instruments with sharp points used suppository—Solid medication that has a base of cocoa
to remove splinters and foreign objects from the skin butter or glycerine and is designed to melt after inser-
and/or tissues. tion into a body cavity (for example, the rectum or
sprain—Injury to a joint accompanied by stretching or vagina).
tearing of the ligaments. suppression—Defense mechanism used by an individ-
sputum—Substance coughed up from the bronchi; con- ual who is aware of unacceptable feelings or thoughts
tains saliva and mucus. but refuses to deal with them.
standard precautions—Recommendations that must surgery—The branch of medicine dealing with opera-
be followed to prevent transmission of pathogenic tive procedures to correct deformities, repair injuries,
organisms by way of blood and body fluids. or treat disease.
statement–receipt—Financial form that shows charges, surgical hose—Elastic or support hose used to support
amounts paid, and balance due. leg veins and increase circulation.
statistical data—Record containing basic facts about a surgical scissors—Special scissors used to cut tissue.
patient, such as address, place of employment, insur- surgical shave—Removal of hair and cleansing of skin
ance, and similar items. prior to an operation.
stereotyping—Process of assuming that everyone in a suture—Surgical stitch used to join the edges of an inci-
particular group is the same. sion or wound; also, an area where bones join or fuse
sterile—Free of all organisms, including spores and together.
viruses. suture-removal set—Set of instruments, including
sterile field—An area that is set up for certain proce- suture scissors and thumb forceps, used to remove
dures and is free from all organisms. stitches (sutures).
sterilization—Process that results in total destruction sympathetic—That division of the autonomic nervous
of all microorganisms; also, surgical procedure that system that allows the body to respond to emergencies
prevents conception of a child. and stress; also, to understand and attempt to solve
sternum—Breastbone. the problems of another.
stethoscope—Instrument used for listening to internal symptom—A subjective indication of disease that is felt
body sounds. by the patient.
stoma—The opening of an ostomy on the abdominal syncope—Fainting; temporary period of unconscious-
wall. ness.
stomach—Enlarged section of the alimentary canal, system—A group of organs and other parts that work
between the esophagus and the small intestine; serves together to perform a certain function.
as an organ of digestion. systemic—Pertaining to the whole body.
stool—Material evacuated from the bowels; feces. systole—Period of work, or contraction, of the heart.
strain—Injury caused by excessive stretching, overuse, systolic pressure—Measurement of blood pressure
or misuse of a muscle. taken when the heart is contracting and forcing blood
stress—Body’s reaction to any stimulus that requires a into the arteries.
person to adjust to a changing environment.
stroke—See cerebrovascular accident. T
subcutaneous—Beneath the skin. tachycardia—Fast, or rapid, heartbeat (usually more
subcutaneous fascia (hypodermis)—Layer of tissue than 100 beats per minute in an adult).
that is under the skin and connects the skin to muscles tachypnea—Respiratory rate above 25 respirations per
and underlying tissues. minute.
Glossary 1049
tactful—Able to do or say the correct thing; thoughtful. tissue forceps—An instrument with one or more fine
tarsal—One of seven bones that forms the instep of the points (teeth) at the tips of blades; used to grasp tis-
foot. sue.
tartar—See calculus. tongue—Muscular organ of the mouth; aids in speech,
teamwork—Cooperative effort by the members of a swallowing, and taste.
group to achieve a common goal. tonometer—An instrument used to measure intraocu-
technician—A level of proficiency usually requiring a lar (within the eye) pressure.
2-year associate’s degree or 3 to 4 years of on-the-job tonsil—Mass of lymphatic tissue found in the pharynx
training. (throat) and mouth.
technologist—A class of expertise in a health career tort—A wrongful or illegal act of civil law not involving a
field, usually requiring at least 3 to 4 years of college contract.
plus work experience. tourniquet—Device used to compress the blood ves-
teeth—Structures in the mouth that physically break sels.
down food by chewing and grinding. towel clamps—Instruments with pointed ends that lock
temperature—The measurement of the balance together; used to attach surgical drapes to each other
between heat lost and heat produced by the body. and/or clamp dissected tissue.
temporal temperature—Measurement of body tem- trachea—Windpipe; air tube from the larynx to the
perature at the temporal artery on the forehead. bronchi.
temporary—Dental material used for restorative pur- tracheostomy—Creation of an opening into the trachea
poses for a short period of time until permanent resto- to facilitate breathing.
ration can be done. transdermal—Through the skin.
tendon—Fibrous connective tissue that connects mus- transfer (gait) belt—Band of fabric or leather that is
cles to bones. placed around a patient’s waist; grasped by the health
tension—Uncomfortable inner sensation, discomfort, care worker during transfer or ambulation to provide
strain, or stress that affects the mind. additional support for the patient.
terminal illness—An illness that will result in death. transfusion—Transfer of blood from one person to
testes—Gonads or endocrine glands that are located in another person; injection of blood or plasma.
the scrotum of the male and that produce sperm and transverse plane—Imaginary line drawn through the
male hormones. body to separate the body into a top half and a bottom
thalamus—That structure in the diencephalon of the half.
brain that acts as a relay center to direct sensory Trendelenburg position—The patient lies on the back
impulses to the cerebrum. with the head lower than the feet, or with both the
therapeutic diet—Diet used in the treatment of dis- head and feet inclined downward.
ease. triage—A method of prioritizing treatment.
therapy—Remedial treatment of a disease or disorder. tricuspid valve—Flap or cusp between the right atrium
thermometer—Instrument used to measure tempera- and right ventricle in the heart.
ture. tri-flow (air–water) syringe—Handpiece in dental
thermotherapy—Use of heat applications for treat- units that provides air, water, or a combination of air
ment. and water for various dental procedures.
thoracic—Pertaining to the chest or thorax. trifurcated—Having three roots (as do some teeth).
thoracic duct—Main lymph duct of the body; drains tuning fork—An instrument that has two prongs and is
lymph from the lymphatic vessels into the left subcla- used to test hearing acuity.
vian vein. 24-hour urine specimen—Special urine test in which
thrombocyte—Also called a platelet; blood cell required all urine produced in a 24-hour period is collected in a
for clotting of the blood. special container.
thrombus—A blood clot. tympanic membrane—The eardrum.
thymus—Organ in the upper part of the chest, lym- typing and crossmatch—A determination of blood
phatic tissue and endocrine gland that atrophies at types and antigens prior to a blood transfusion.
puberty.
thyroid—Endocrine gland that is located in the neck and U
regulates body metabolism. ulcer—An open lesion on the skin or mucous mem-
tibia—Inner and larger bone of the lower leg, between brane.
the knee and ankle. ulna—Long bone in the forearm, between the wrist and
time management—System of practical skills that elbow.
allows an individual to use time in the most effective ulnar deviation—Moving toward the little finger side of
and productive way. the hand.
tissue—A group of similar cells that join together to per- ultrasonic unit—Piece of equipment that cleans with
form a particular function. sound waves.
1050 GLOSSARY
ultrasonography—Noninvasive, computerized scan- vein—Blood vessel that carries blood back to the heart.
ning technique that uses high-frequency sound waves venipuncture—Surgical puncture of a vein; inserting a
to create pictures of body parts. needle into a vein.
ultra-speed handpiece—High-speed handpiece used venous—Pertaining to the veins.
in dental units to cut and prepare a tooth during a den- ventilation—Process of breathing.
tal procedure. ventral—Pertaining to the front, or anterior, part of the
umbilicus—Navel; in slang, “belly button.” body; in front of.
Universal/National Numbering System—Abbrevi- ventricle—One of two lower chambers of the heart; also,
ated means of identifying the teeth. a cavity in the brain.
uremia—Excessive amounts of urea (a waste product) in venule—The smallest type of vein; connects capillaries
the blood. and veins.
ureter—Tube that carries urine from the kidney to the vertebrae—Bones of the spinal column.
urinary bladder. vertigo—Sensation of dizziness.
ureterostomy—Formation of an opening on the vesicle—Blister; a sac full of water or tissue fluid.
abdominal wall for drainage of urine from a ureter. vestibule—Small space or cavity at the beginning of a
urethra—Tube that carries urine from the urinary blad- canal.
der to outside the body. veterinary—Pertaining to the medical treatment of ani-
urinalysis—Examination of urine by way of physical, mals.
chemical, or microscopic testing. villi—Tiny projections from a surface; in the small intes-
urinary-drainage unit—Special device used to collect tine, projections that aid in the absorption of nutri-
urine and consisting of tubing and a collection con- ents.
tainer usually connected to a urinary catheter. virus—One of a large group of very small microorgan-
urinary meatus—External opening of the urethra. isms, many of which cause disease.
urinary sediments—Solid materials suspended in visceral—Pertaining to organs.
urine. visual acuity—Ability to perceive and comprehend light
urinate—To expel urine from the bladder. rays; seeing.
urine—The fluid excreted by the kidney. vital signs—Determinations that provide information
urinometer—Calibrated device used to measure the about body conditions; include temperature, pulse,
specific gravity of urine. respirations, and blood pressure.
urology—The branch of medicine dealing with urine vitamins—Organic substances necessary for body pro-
and diseases of the urinary tract. cesses and life.
urticaria—Hives. vitreous humor—Jelly-like mass that fills the cavity of
uterus—Muscular, hollow organ that serves as the organ the eyeball, behind the lens.
of menstruation and the area for development of the void—To empty the bladder; urinate.
fetus in the female body. volume—The degree of strength of a pulse (for example,
strong or weak).
V voluntary—Under one’s control; done by one’s choice or
vaccine—Substance given to an individual to produce desire.
immunity to a disease. vomit—To expel material from the stomach and/or
vagina—Tube from the uterus to outside the body in a intestine through the mouth and/or nose.
female individual. vulva—External female genitalia; includes the labia
vaginal irrigation—Also called douche; injection of majora, labia minora, and clitoris.
fluid into the vagina.
variable expense—In a budget, an expense that can W
change or be adjusted (for example, expenses for walker—A device that has a metal framework and aids in
clothing and entertainment). walking.
varicose—Pertaining to distended, swollen veins. warm-water bag—Rubber or plastic device designed to
vas deferens—Also called the ductus deferens; the tube hold warm water for dry-heat application.
that carries sperm and semen from the epididymis to wellness—State of being in good health; well.
the ejaculatory duct in the male body. wheezing—Difficult breathing with a high-pitched whis-
vascular—Pertaining to blood vessels. tling or sighing sound during expiration.
vasoconstriction—Constriction (decrease in diameter) white blood cell—see leukocyte.
of the blood vessels. withdrawal—Defense mechanism in which an individ-
vasodilation—Dilation (increase in diameter) of the ual either ceases to communicate or physically
blood vessels. removes self from a situation.
vector—A carrier of disease; an insect, rodent, or small word root—Main word or part of word to which prefixes
animal that transmits disease. and suffixes can be added.
Glossary 1051
Workers’ Compensation—Payment and care provided Y

to an individual who is injured on the job. yellow marrow—Soft tissue in the diaphyses of long
wound—An injury to tissues. bones.
X
xiphoid process—The small, bony projection at the
lower end of the sternum (breastbone).
References
Acello, B. (2002). The OBRA guidelines for quality American Heart Association. (2005). American Heart
improvement (4th ed.). Clifton Park, NY: Delmar Association to your health: A guide to health smart liv-
Learning. ing. Dallas, TX: American Heart Association.
Acello, B. (2002). The OSHA handbook: Guidelines for American Heart Association. (2006). BLS for healthcare
compliance in health care facilities (3rd ed.). Clifton providers. Dallas, TX: American Heart Association.
Park, NY: Delmar Learning. American Heart Association. (2006). Handbook of emer-
Acello, B. (2005). Nursing assisting: Essentials for long- gency cardiovascular care for healthcare providers. Dal-
term care (2nd ed.). Clifton Park, NY: Delmar Learn- las, TX: American Heart Association.
ing. American Heart Association. (2006). Heart diseases and
Acello, B. (2005). Nutrition assistant essentials. Clifton stroke statistics. Dallas, TX: American Heart Association.
Park, NY: Delmar Learning. American Heart Association. (2006). Know the facts: Get
Acello, B. (2007). Advanced skills for health care providers the stats. Dallas, TX: American Heart Association.
(2nd ed.). Clifton Park, NY: Delmar Learning. American Heart Association. (2006). Stroke facts 2006: All
Aehlert, B. (2006). ECGs made easy (3rd ed.) St. Louis, MO: Americans. Dallas, TX: American Heart Association.
Mosby. American Heart Association. (2007). Heartsaver® AED.
Aehlert, B. (2007). ACLS (Advanced Cardiac Life Support) Dallas, TX: American Heart Association.
review (3rd ed.). St. Louis, MO: Mosby. American Heart Association. (2007). Heartsaver® CPR.
Agency for Instructional Technology. (2002). Communi- Dallas, TX: American Heart Association.
cating with your team (2nd ed.). Cincinnati, OH: American Heart Association. (2007). Heartsaver® first
South-Western. aid. Dallas, TX: American Heart Association.
Agency for Instructional Technology. (2002). Communi- American Medical Association. (2006). Principles of ICD-
cation and diversity (2nd ed.). Cincinnati, OH: South- 9-CM coding (3rd ed.). Chicago: American Medical
Western. Association.
Agency for Instructional Technology. (2002). Communi- American Medical Association. (2009). Current Proce-
cation 2000: Resolving problems and conflicts (2nd ed.). dural Terminology (CPT). Chicago: American Medical
Cincinnati, OH: South-Western. Association.
Aiken, T. D. (2003). Legal and ethical issues in health occu- American Medical Association. (2009). Health professions
pations. Philadelphia: W. B. Saunders. career and education directory. Chicago: American
Allen, E., & Marotz, L. (2007). Developmental profiles: Medical Association.
Pre-birth to eight (5th ed.). Clifton Park, NY: Delmar American Medical Association. (2009). ICD-9-CM coding
Learning. handbook. Chicago: American Medical Association.
Alternative Link Systems, Inc. (2001). The state legal guide American Red Cross. (2005). Bloodborne pathogens train-
to complementary and alternative medicine and nursing: Preventing disease transmission. Boston: StayWell.
ing. Clifton Park, NY: Delmar Learning. American Red Cross. (2005). Disaster preparedness guide.
Altman, G. (2004). Delmar’s fundamental and advanced Washington, DC: American Red Cross.
nursing skills (2nd ed.). Clifton Park, NY: Delmar American Red Cross. (2005). First aid fast. Boston: StayWell.
Learning. American Red Cross. (2006). CPR/AED for the professional
American Heart Association. (2004). Recommendations rescuer. Boston: StayWell.
for blood pressure measurements in humans. Dallas, American Red Cross. (2006). General first aid/CPR/AED.
TX: American Heart Association. Boston: StayWell.
References 1053
American Red Cross. (2006). Responding to emergencies. Burke, L., & Weill, B. (2005). Information technology for
Boston: StayWell. the health professions (2nd ed.). Upper Saddle River,
Anderson, P., & Pendleton, A. (2001). The dental assistant NJ: Prentice Hall.
(7th ed.). Clifton Park, NY: Delmar Learning. Burkhardt, M., & Nathaniel, A. (2002). Ethics and issues in
Andrews, M., & Boyle, J. (2002). Transcultural concepts in contemporary nursing (2nd ed.). Clifton Park, NY: Del-
nursing care (4th ed.). Philadelphia: Lippincott Wil- mar Learning.
liams & Wilkins. Burkhardt, M. A., & Naqai-Jacobson, M. G. (2002). Spiritu-
Anspaugh, D., Hamrick, M., & Rosato, F. (2006). Wellness: ality: Living our connectedness. Clifton Park, NY: Del-
Concepts and applications (6th ed.). New York: mar Learning.
McGraw-Hill. Burton, G. R., & Engelkirk, P. G. (2006). Microbiology for
Association of Surgical Technologists. (2004). Surgical the health sciences (8th ed.). Philadelphia: Lippincott
technology for the surgical technologist (2nd ed.). Clif- Williams & Wilkins.
ton Park, NY: Delmar Learning. Capellini, S. (2006). Massage therapy career guide for
Atkinson, P., & Miller, D. (2004). Medical office practice hands-on success (2nd ed.). Clifton Park, NY: Delmar
(7th ed.). Clifton Park, NY: Delmar Learning. Learning.
Bailey, L. (2007). Working (4th ed.). Cincinnati, OH: South- Carlton, R. R., & McKenna Adler, A. (2006). Principles of
Western. radiographic imaging (4th ed.). Clifton Park, NY: Del-
Beck, M. (2006). Theory and practice of therapeutic mas- mar Learning.
sage (4th ed.). Clifton Park, NY: Delmar Learning. Charlesworth, R. (2004). Understanding child develop-
Beebe, R., & Funk, D. (2005). Fundamentals of emergency ment (6th ed.). Clifton Park, NY: Delmar Learning.
care (2nd ed.). Clifton Park, NY: Delmar Learning. Chernega, J. (2002). Emergency guide for dental auxilia-
Beers, M., & Berkow, R. (2006). The Merck manual of diag- ries (3rd ed.). Clifton Park, NY: Delmar Learning.
nosis and therapy (18th ed.). Whitehouse Station, NJ: Cohen, B. (2005). Memmler’s structure and function of the
Merck and Company. human body (8th ed.). Philadelphia: Lippincott Wil-
Beers, M., & Jones, T. V. (2005). The Merck manual of geri- liams & Wilkins.
atrics (3rd ed.). Whitehouse Station, NJ: Merck and Cohen, B. (2005). Memmler’s the human body in health
Company. and disease (10th ed.). Philadelphia: Lippincott Wil-
Beers, M., & Jones, T. V. (2005). The Merck manual of health liams & Wilkins.
and aging. Whitehouse Station, NJ: Merck and Com- Coker Group. (2005). Handbook of medical office commu-
pany. nications: Effective letters, memos, and e-mails. Chi-
Bird, D., & Robinson, D. S. (2005). Torres and Ehrlich mod- cago: American Medical Association.
ern dental assisting (8th ed.). Philadelphia: W. B. Saun- Colbert, B. J. (2006). Workplace readiness for health occu-
ders. pations. (2nd ed.). Clifton Park, NY: Delmar Learning.
Bonewit-West, K., Fulcher, E., & Burton, B. (2006). Clinical Colwell Systems. (N. D.). Appointment control system.
procedures for medical assistants (6th ed.). Philadel- Roselle, IL: Colwell Systems.
phia: W. B. Saunders. Comer, S. R. (2005). Delmar’s geriatric nursing care plans.
Bos, T. J., & Somers, K. D. (2006). Microbiology and infec- Clifton Park, NY: Delmar Learning.
tious diseases. New York: McGraw-Hill. Conklin, W. A., White, G., Cothren, C., Williams, D., &
Bowie, M. J., & Schaffer, R. M. (2006). Understanding ICD- Davis, R. (2005). Principles of computer security. New
9-CM coding. Clifton Park, NY: Delmar Learning. York: McGraw-Hill.
Bowman, M., & Lawlis, G. F. (2003). Complementary and Connor, L., Snyder, D., & Lorenz, G. (2005). Kinesiology
alternative medicine management. Clifton Park, NY: foundations for OTAs and PTAs. Clifton Park, NY: Del-
Delmar Learning. mar Learning.
Boyd, L. B. (2005). Dental instruments (2nd ed.). Philadel- Correa, C. (2005). Getting started in the computerized
phia: W. B. Saunders. medical office: Fundamentals and practice. Clifton
Brannigan, M. (2005). Ethics across cultures. New York: Park, NY: Delmar Learning.
McGraw-Hill. Course Technology. (2005). Guide to the Internet (3rd ed.).
Brunzel, N. A. (2004). Fundamentals of urine and Cincinnati, OH: South-Western.
body fluid analysis (2nd ed.). Philadelphia: W. B. Saun- Covell, A. (2008). Coding workbook for the physician’s
ders. office. Clifton Park, NY: Delmar Learning.
Buck, G. (2002). Preparing for biological terrorism: An Cowan, M., & Park Talaro, K. (2006). Microbiology. New
emergency services guide. Clifton Park, NY: Delmar York: McGraw-Hill.
Learning. Craig, R., Powers, J., & Wataha, J. (2004). Dental materials:
Buck, G., Buck, L., & McGill, B. (2003). Preparing for ter- Properties and manipulation (8th ed.). St. Louis, MO:
rorism: The public safety communicator’s guide. Clifton Mosby.
Park, NY: Delmar Learning. Cronin, A., & Mandich, M. B. (2005). Human development
Buckley, W., & Okrent, K. (2004). Torts and personal injury and performance throughout the lifespan. Clifton Park,
law (3rd ed.). Clifton Park, NY: Delmar Learning. NY: Delmar Learning.
1054 REFERENCES
Cumming, A., Simpson, K., & Brown, D. (2007). Comple- Doscher, M. (2005). HIPAA: A short- and long-term per-
mentary and alternative medicine. New York: Churchill spective for health care. Chicago: American Medical
Livingstone. Association.
Dalton, M., Hoyle, D. G., & Watts, M. W. (2006). Human Durgin, J. M., & Hanan, Z. I. (2005). Pharmacy practice for
relations (3rd ed.). Cincinnati, OH: South-Western. technicians (3rd ed.). Clifton Park, NY: Delmar Learning.
Damjanov, I. (2006). Pathology for the health professions Edge, R., & Groves, J. (2006). Ethics of health care: A guide
(3rd ed.). Philadelphia: W. B. Saunders. for clinical practice (3rd ed.). Clifton Park, NY: Delmar
Daniels, R. (2002). Delmar’s guide to laboratory and diag- Learning.
nostic tests. Clifton Park, NY: Delmar Learning. Eggland, S. A., & WIlliams, J. W. (2005). Human relations
Daniels, R., Nosek, L., & Nicoll, L. (2007). Contemporary for career success (6th ed.). Cincinnati, OH: South-
medical-surgical nursing. Clifton Park, NY: Delmar Western.
Learning. Ehrlich, A., & Schroeder, C. L. (2005). Medical terminology
D’Avanzo, C., & Geissler, E. (2003). Pocket guide to cultural for health professions (5th ed.). Clifton Park, NY: Del-
assessment (3rd ed.). St. Louis, MO: Mosby. mar Learning.
Davies, J. (2002). Essentials of medical terminology (2nd Elahi, A. (2006). Data, network, and Internet communica-
ed.). Clifton Park, NY: Delmar Learning. tions technology. Clifton Park, NY: Delmar Learning.
Davies, J. J. (2007). Illustrated guide to medical terminol- Elling, Bob. (2003). Principles of patient assessment in
ogy. Clifton Park, NY: Delmar Learning. EMS. Clifton Park, NY: Delmar Learning.
Davis, B. K. (2002). Phlebotomy: A customer service Engelkirk, P., & Burton, G. (2007). Burton’s microbiology
approach. Clifton Park, NY: Delmar Learning. for the health sciences (8th ed.). Philadelphia: Lippin-
Deem, S., & Deem, J. (2000). Health care exploration. Clif- cott Williams & Wilkins.
ton Park, NY: Delmar Learning. Estes, M. E. Z. (2006). Health assessment (3rd ed.). Clifton
DeLaune, S. C., & Ladner, P. K. (2006). Fundamentals of Park, NY: Delmar Learning.
nursing, standards and practice (3rd ed.). Clifton Park, Estridge, B., Reynolds, A., & Walters, N. (2000). Basic med-
NY: Delmar Learning. ical laboratory techniques (4th ed.). Clifton Park, NY:
Delmar’s medical terminology Flash! Computerized flash- Delmar Learning.
cards. (2002). Clifton Park, NY: Delmar Learning. Evashwick, C. (2005). The continuum of long-term care
Dennerll, J. T. (2007). Medical terminology made easy (4th (3rd ed.). Clifton Park, NY: Delmar Learning.
ed.). Clifton Park, NY: Delmar Learning. Farr, M. (2006). Job searching fast and easy. Clifton Park,
Dennerll, J. T., & Davis, P. (2005). Medical terminology: A NY: Delmar Learning.
programmed systems approach (9th ed.). Clifton Park, Farr, M. (2006). Landing your dream job. Clifton Park, NY:
NY: Delmar Learning. Delmar Learning.
DesJardins, T. (2002). Cardiopulmonary anatomy and Farr, M. (2006). Seven step job search (2nd ed.). Indianap-
physiology (4th ed.). Clifton Park, NY: Delmar Learn- olis, IN: Jist Works.
ing. Feldstein, P. J. (2005). Health care economics (6th ed.).
Deter, L. L. (2006). Basic medication administration skills. Clifton Park, NY: Delmar Learning.
Clifton Park, NY: Delmar Learning. Fetrow, C., & Avila, J. R. (2003). Professional’s handbook of
Deutsch, J. E., & Anderson, E. S. (2006). Complementary complementary and alternative medicine (3rd ed.).
therapies for physical therapy. Philadelphia: W. B. Philadelphia: Lippincott Williams & Wilkins.
Saunders. Finkbeiner, B., & Finkbeiner, C. A. (2006). Practice man-
Diamond, M. (2007). Understanding hospital coding and agement for the dental team (6th ed.). St. Louis, MO:
billing. Clifton Park, NY: Delmar Learning. Mosby.
Dietz-Bourquignon, E. (2002). Safety standards and infec- Flight, M. R. (2004). Law, liability, and ethics for the medi-
tion control for dental assistants. Clifton Park, NY: Del- cal office professional (4th ed.). Clifton Park, NY: Del-
mar Learning. mar Learning.
Dietz-Bourquignon, E. (2006). Materials and procedures Fordney, M. (2006). Insurance handbook for the medical
for today’s dental assistants. Clifton Park, NY: Delmar office (9th ed.). Philadelphia: W. B. Saunders.
Learning. Fordney, M., French, L., & Follis, J. (2004). Administrative
Dikel, M., & Roehm, F. (2007). Guide to Internet job search- medical assisting (5th ed.). Clifton Park, NY: Delmar
ing. Indianapolis, IN: Jist Works. Learning.
Diller, J., & Moule, J. (2005). Cultural competence. Pacific Fosegan, J. S. (2003). Alphabetic indexing rules: Applica-
Grove, CA: Brooks/Cole. tion by computer (4th ed.). Cincinnati, OH: South-
Diller, J. (2007). Cultural diversity: A primer for the human Western.
services (3rd ed.). Pacific Grove, CA: Brooks/Cole. Fosegan, J. S., & Ginn, M. L. (2000). Business records con-
Dofka, C. (2007). Dental terminology (2nd ed.). Clifton trol (8th ed.). Cincinnati, OH: South-Western.
Park, NY: Delmar Learning. Frazier, M. S., & Drzymkowski, J. (2004). Essentials of
Dorland’s illustrated medical dictionary (31st ed.). (2007). human disease and conditions (3rd ed.). Philadelphia:
Philadelphia: W. B. Saunders. W. B. Saunders.
References 1055
Fremgen, B. F. (2005). Medical law and ethics (2nd ed.). Heller, M., & Krebs, C. (2004). Delmar learning’s clinical
Upper Saddle River, NJ: Prentice Hall. handbook for the medical office (2nd ed.). Clifton Park,
Frey, K., & Price, P. (2005). Surgical anatomy and physiol- NY: Delmar Learning.
ogy for surgical technologists. Clifton Park, NY: Delmar Heller, M., & Veach, L. (2007). Clinical medical assisting.
Learning. Clifton Park, NY: Delmar Learning.
Frisch, B. (2007). Correct coding for medicare, compliance, Henderson, D. A., O’Toole, T., & Inglesly, T. V. (2005). Bioter-
and reimbursement. Clifton Park, NY: Delmar Learning. rorism: A guideline for medical and public health man-
Fry, R. (2003). 101 great resumes (2nd ed.). Clifton Park, agement. Chicago: American Medical Association.
NY: Delmar Learning. Hernandez, L. de. (2002). Emergencia: Emergency transla-
Fry, R. (2005). Get organized (3rd ed.). Clifton Park, NY: tion manual. Clifton Park, NY: Delmar Learning.
Delmar Learning. Hirsch, A. (2005). Job search and career checklist. India-
Fry, R. (2005). How to study (6th ed.). Clifton Park, NY: napolis, IN: Jist Works.
Delmar Learning. Hoeltke, L. (2006). Complete textbook of phlebotomy (3rd
Fry, R. (2007). 101 great answers to the toughest interview ed.). Clifton Park, NY: Delmar Learning.
questions (5th ed.). Clifton Park, NY: Delmar Learning. Hoeltke, L. (2006). Phlebotomy, procedures and practices.
Fry, R. (2007). 101 smart questions to ask on your interview Clifton Park, NY: Delmar Learning.
(2nd ed.). Clifton Park, NY: Delmar Learning. Hoffman, S. M. (2006). Child care in action: Infants and
Gartee, R. (2004). The medical manager, student edition toddlers. Clifton Park, NY: Delmar Learning.
10. Clifton Park, NY: Delmar Learning. Hogan, M. (2003). Four skills of cultural diversity: A pro-
Garwood-Growers, A., Tingle, J., & Wheat, K. (2005). Con- cess for understanding and practice (2nd ed.). Pacific
temporary issues in healthcare law and ethics. Phila- Grove, CA: Brooks/Cole.
delphia: W. B. Saunders. Hogstel, M. (2001). Nursing care of the older adult. Clifton
Gaviola, S. (2005). My pocket mentor, a health care profes- Park, NY: Delmar Learning.
sional’s guide to success. Clifton Park, NY: Delmar Hosley, J., & Molle-Matthews, E. (2006). A practical guide
Learning. to therapeutic communication for health professionals.
Giger, J. N., & Davidhizar, R. E. (2004). Transcultural nurs- Philadelphia: W. B. Saunders.
ing: Assessment and intervention (4th ed.). St. Louis, Hover-Kramer, D. (2002). Healing touch: A guide book for
MO: Mosby. practitioners (2nd ed.). Clifton Park, NY: Delmar Learn-
Gould, B. (2006). Pathophysiology for the health related ing.
professions (3rd ed.). Philadelphia: W. B. Saunders. Huber, F. E., & Wells, C. L. (2006). Therapeutic exercise:
Graf, J. (2000). Dental charting: A standard approach. Clif- Treatment planning for progression. Philadelphia: W. B.
ton Park, NY: Delmar Learning. Saunders.
Green, M. (2007). 3-2-1 code. Clifton Park, NY: Delmar Humphrey, D., & Sigler, K. (2004). Contemporary medical
Learning. office procedures (3rd ed.). Clifton Park, NY: Delmar
Green, M., & Bowie, M. J. (2005). Essentials of health infor- Learning.
mation management: Principles and practices. Clifton Johns, M. (2002). Information management for health
Park, NY: Delmar Learning. professions. (2nd ed.). Clifton Park, NY: Delmar Learn-
Green, M., & Rowell, J. C. (2006). Understanding health ing.
insurance: A guide to billing and reimbursement (8th Johnson, S., & McHugh, C. (2006). Understanding medical
ed.). Clifton Park, NY: Delmar Learning. coding: A comprehensive guide (2nd ed.). Clifton Park,
Grover-Lakomia, L., & Fong, E. (2000). Microbiology for NY: Delmar Learning.
health careers (6th ed.). Clifton Park, NY: Delmar Jonas, W. (2005). Mosby’s dictionary of complementary
Learning. and alternative medicine. St. Louis, MO: Mosby.
Haring, J. I., & Howerton, L. J. (2006). Dental radiography Jones, B. D., & Davies, J. J. (2006). Delmar’s comprehensive
(3rd ed.). Philadelphia: Saunders. medical terminology (2nd ed.). Clifton Park, NY: Del-
Haroun, L. (2006). Career development for health profes- mar Learning.
sionals (2nd ed.). Philadelphia: Saunders. Kalanick, K. (2004). Phlebotomy technician specialist. Clif-
Haroun, L., & Royce, S. (2004). Delmar’s teaching ideas ton Park, NY: Delmar Learning.
and classroom activities for health occupations. Clifton Kaliski, B. S., Schultheis, R., & Passalacqua, D. (2006).
Park, NY: Delmar Learning. Keeping financial records for business (10th ed.). Cin-
Hegner, B., & Acello, B. (2004). On the job: The essentials of cinnati, OH: South-Western.
nursing assisting. Clifton Park, NY: Delmar Learning. Keegan, L. (2001). Healing with complementary and alter-
Hegner, B., Acello, B., & Caldwell, E. (2004). Nursing assis- native therapies. Clifton Park, NY: Delmar Learning.
tant: A nursing process approach (9th ed.). Clifton Park, Keegan, L. (2002). Healing nutrition (2nd ed.). Clifton
NY: Delmar Learning. Park, NY: Delmar Learning.
Hegner, B., Needham, J., & Gerlach, M. J. (2007). Assisting Keir, L., Krebs, C., & Wise, B. A. (2006). Medical assisting:
in long-term care (5th ed.). Clifton Park, NY: Delmar Administrative and clinical competencies 2006 update
Learning. (5th ed.). Clifton Park, NY: Delmar Learning.
1056 REFERENCES
Kelz, R. (1999). Conversational Spanish for health profes- Malarkey, L. M., & McMorrow, M. E. (2005). Saunders
sions. Clifton Park, NY: Delmar Learning. nursing guide to laboratory and diagnostic tests. Phila-
Kennamer, M. (2005). Math for health care professionals. delphia: W. B. Saunders.
Clifton Park, NY: Delmar Learning. Mandleco, B. (2004). Growth and development handbook:
Kennamer, M. (2007). Basic infection control for the health Newborn through adolescent. Clifton Park, NY: Delmar
care professional (2nd ed.). Clifton Park, NY: Delmar Learning.
Learning. Mappes, T., & DeGrazia, D. (2006). Biomedical ethics (6th
Klieger, D., & Fulcher, E. (2006). Saunders textbook of ed.). New York: McGraw-Hill.
medical assisting. Philadelphia: W. B. Saunders. Marotz, L., Cross, M. Z., Rush, J. (2005). Health, safety, and
Klinoff, R. (2007). Introduction to fire protection (3rd ed.). nutrition for the young child (6th ed.). Clifton Park, NY:
Clifton Park, NY: Delmar Learning. Delmar Learning.
Koprucki, V. (2007). Client-centered care for clinical medi- Maville, J. (2002). Health promotion in nursing. Clifton
cal assisting. Clifton Park, NY: Delmar Learning. Park, NY: Delmar Learning.
Kovanda, B. (1999). Multiskilling: Waived laboratory test- McArdle, W., Katch, F., & Katch, V. (2006). Exercise physiol-
ing for the health care provider. Clifton Park, NY: Del- ogy: Energy, nutrition, and human performance (6th
mar Learning. ed.). Philadelphia: Lippincott Williams & Wilkins.
Krager, D., & Krager, C. (2005). HIPAA for medical office McCutcheon, M., & Phillips, M. (2006). Exploring health
personnel. Clifton Park, NY: Delmar Learning. careers (3rd ed.). Clifton Park, NY: Delmar Learning.
Kramer, C. (2002). Success in on-line learning. Clifton McElroy, O. H., & Grabb, L. L. (2006). Spanish-English
Park, NY: Delmar Learning. English-Spanish medical dictionary (3rd ed.). Philadel-
Krantman, S. (2001). The resume writer’s workbook (2nd phia: Lippincott Williams & Wilkins.
ed.). Clifton Park, NY: Delmar Learning. McWay, D. (2003). Legal aspects of health information
Kubler-Ross, E. (1975). Death: The final stage of growth. management (2nd ed.). Clifton Park, NY: Delmar
Englewood Cliffs, NJ: Prentice-Hall. Learning.
Kuhns, D. J., Noonan Rice, P., & Winslow, L. L. (2006). Means, T. (2004). Business communications. Cincinnati,
Health unit coordinator, 21st century professional. Clif- OH: South-Western.
ton Park, NY: Delmar Learning. Merriam-Webster’s medical desk dictionary (3rd ed.).
Lafferty, S., & Baird, M. (2001). Tele-nurse: Telephone tri- (2006). Clifton Park, NY: Delmar Learning.
age protocols. Clifton Park, NY: Delmar Learning. Miller, C. H., & Palenik, C. J. (2005). Infection control and
Layman, D. (2006). Medical terminology demystified. New management of hazardous materials for the dental
York: McGraw-Hill. team (3rd ed.). St. Louis, MO: Mosby.
Leininger, M., & McFarland, M. R. (2002). Transcultural Milliken, M. E. (2004). Understanding human behavior
nursing. New York: McGraw-Hill. (7th ed.). Clifton Park, NY: Delmar Learning.
Leonard, P. C. (2007). Quick and easy medical terminology Mitchell, J., & Haroun, L. (2007). Introduction to health
(5th ed.). Philadelphia: W. B. Saunders. care (2nd ed.). Clifton Park, NY: Delmar Learning.
Lesmeister, M. B. (2005). Math basics for the health care Mitchell, M. K. (2003). Nutrition across the life span (2nd
professional (2nd ed.). Upper Saddle River, NJ: Prentice ed.). Philadelphia: W. B. Saunders.
Hall. Mitchell, M. (2004). Dental instruments: A pocket guide to
Lesmeister, M. B. (2007). Writing basics for the health care identification. Philadelphia: Lippincott Williams &
professional (2nd ed.). Upper Saddle River, NJ: Prentice Wilkins.
Hall. Mosby’s dictionary of medicine, nursing, and health pro-
Lewis, K., & Handal, K. (2001). Sensible application of the fessions (7th ed.). (2006). St. Louis, MO: Mosby.
ECG: A pocket guide. Clifton Park, NY: Delmar Learning. Moisio, M. (2002). Medical terminology: A student cen-
Libster, M. (2002). Delmar’s integrative herb guide for tered approach. Clifton Park, NY: Delmar Learning.
nurses. Clifton Park, NY: Delmar Learning. Moisio, M. (2006). A guide to health insurance billing (2nd
Limmer, D., O’Keefe, M., Dickinson, E., Grant, H., Murray, ed.). Clifton Park, NY: Delmar Learning.
B., & Bergeron, J. D. (2005). Emergency care (10th ed.). Monahan, F. D., Sands, J., Marek, J., Neighbors, M., &
Upper Saddle River, NJ: Brady/Prentice Hall. Green-Nigro, C. (2007). Medical surgical nursing:
Lindh, W. (2002). Therapeutic communications for health Health and illness perspectives (8th ed.). St. Louis, MO:
professionals (2nd ed.). Clifton Park, NY: Delmar Learn- Mosby.
ing. Moss, E. J. (2004). Basic keyboarding for the medical office
Lindh, W., Pooler, M., Tamparo, C., & Dahl, B. (2006). assistant (3rd ed.). Clifton Park, NY: Delmar Learning.
Thomson Delmar learning’s comprehensive medical Mullins, D. F. (2006). 501 human diseases. Clifton Park,
assisting: Administrative and clinical competencies NY: Delmar Learning.
(3rd ed.). Clifton Park, NY: Delmar Learning. Mulvihill, M. L., Zelman, M., Holdaway, P., Tompary, E., &
Makely, S. (1999). Multiskilling: Team building for the Raymond, J. (2006). Human diseases: A systemic
health care provider. Clifton Park, NY: Delmar approach (6th ed.). Upper Saddle River, NJ: Prentice
Learning. Hall.
References 1057
Munoz, C., & Luckmann, J. (2005). Transcultural commu- Pigford, L. (2001). The successful interview and beyond.
nication in nursing (2nd ed.). Clifton Park, NY: Delmar Clifton Park, NY: Delmar Learning.
Learning. Potts, N., & Mandleco, B. (2007). Pediatric nursing: Caring
Myers, J., Neighbors, M., & Tannehill-Jones, R. (2002). for children and their families (2nd ed.). Clifton Park,
Principles of pathophysiology and emergency medical NY: Delmar Learning.
care. Clifton Park, NY: Delmar Learning. Price, P., & Frey, K. (2003). Microbiology for surgical tech-
Nasso, J., & Celia, L. (2007). Dementia care. Clifton Park, nologists. Clifton Park, NY: Delmar Learning.
NY: Delmar Learning. Quill, T. (1993). Death and dignity. New York: W. W. Norton
National Health Council. (2002). 300 ways to put your tal- and Company.
ent to work in the health field. New York: National Quill, T., & Battin, M. P. (2004). Physician-assisted dying:
Health Council. The case for palliative care and patient choice. Balti-
National Health Council. (2008). Guide to voluntary health more, MD: Johns Hopkins University Press.
agencies. New York: National Health Council. Raffel, M. W., & Barsukiewicz, C. K. (2002). The US health
National Safety Council. (2007). Standard first aid, CPR, system origins and functions (5th ed.). Clifton Park, NY:
and AED (2nd ed.). New York: McGraw-Hill. Delmar Learning.
Neighbors, M., & Tannehill-Jones, R. (2006). Human dis- Rasberry, R. (2004). Employment strategies for career suc-
eases (2nd ed.). Clifton Park, NY: Delmar Learning. cess. Cincinnati, OH: South-Western.
Nettina, S. (2005). Lippincott manual of nursing practice Reichman, E. F. (2007). Pocket atlas of emergency proce-
(8th ed.). Philadelphia: Lippincott Williams & Wilkins. dures. New York: McGraw-Hill.
Nicoll, L. (2009). CIN: Computers, informatics, nursing. Rice, J. (2006). Principles of pharmacology for medical
Philadelphia: Lippincott Williams & Wilkins. assisting (4th ed.). Clifton Park, NY: Delmar Learning.
Nielsen, R. (2000). OSHA regulations and guidelines: A Rios, J., & Fernandez, J. (2005). Spanish for health care
guide for health care providers. Clifton Park, NY: Del- providers. New York: McGraw-Hill.
mar Learning. Rizzo, D. (2006). Delmar’s fundamentals of anatomy
Nix, S. (2005). Williams’ basic nutrition and diet therapy and physiology (2nd ed.). Clifton Park, NY: Delmar
(12th ed.). St. Louis, MO: Mosby. Learning.
Nobles, S. (2002). Delmar’s drug reference for health care Robertson, C. (2007). Safety, health, and nutrition in
professionals. Clifton Park, NY: Delmar Learning. early education (3rd ed.). Clifton Park, NY: Delmar
Nowak, T. J., & Handford, A. G. (2004). Pathophysiology Learning.
concepts and applications for health care professionals Robinson, J., & McCormick, D. J. (2005). Essentials of health
(3rd ed.). New York: McGraw-Hill. and wellness. Clifton Park, NY: Delmar Learning.
O’Donnell, M. (2002). Health promotion in the workplace Roth, R. A., & Townsend, C. E. (2007). Nutrition and diet
(3rd ed.). Clifton Park, NY: Delmar Learning. therapy (9th ed.). Clifton Park, NY: Delmar Learning.
Olson, M. (2002). Healing the dying (2nd ed.). Clifton Park, Ryan, J. S. (2006). Managing your personal finances (5th
NY: Delmar Learning. ed.). Cincinnati, OH: South-Western.
Papalia, D. E., Sterns, H., Feldman, R., & Camp, C. (2007). Saba, V., & McCormick, K. (2006). Essentials of computers:
Adult development and aging (3rd ed.). New York: Nursing informatics (4th ed.). New York: McGraw-Hill.
McGraw-Hill. Schultheis, R., & Kaczmarski, R. (2006). Business math
Papalia, D. E., Wendkos Olds, S., & Duskin Feldman, R. (16th ed.). Cincinnati, OH: South-Western.
(2006). A child’s world: Infancy through adolescence Scott, A., & Fong, E. (2004). Body structures and functions
(10th ed.). New York: McGraw-Hill. (10th ed.). Clifton Park, NY: Delmar Learning.
Parry, J., & Ryan, A. (2003). A cross-cultural look at death, Scott, A., Fong, E., & Beebee, R. (2002). Functional anat-
dying, and religion. New York: McGraw-Hill. omy for emergency medical services. Clifton Park, NY:
Payne, R. A. (2005). Relaxation techniques: A practical Delmar Learning.
handbook for the health care professional (3rd ed.). Segen, J. (2006). Concise dictionary of modern medicine.
New York: Churchill Livingston. New York: McGraw-Hill.
Peden, A. (2005). Comparative health information man- Shimeld, L. (1999). Essentials of diagnostic microbiology.
agement (2nd ed.). Clifton Park, NY: Delmar Learning. Clifton Park, NY: Delmar Learning.
Phinney, D., & Halstead, J. (2002). Delmar’s handbook of Short, M. J. (2003). Head, neck, and dental anatomy (3rd
essential skills and procedures for chairside dental ed.). Clifton Park, NY: Delmar Learning.
assisting. Clifton Park, NY: Delmar Learning. Shortell, S., & Kaluzny, A. (2006). Health care manage-
Phinney, D., & Halstead, J. (2007). Dental assisting instrument, organization, design, and behavior (5th ed.).
ment guide. Clifton Park, NY: Delmar Learning. Clifton Park, NY: Delmar Learning.
Phinney, D., & Halstead, J. (2009). Delmar’s dental assist- Simmers, L. (2005). Practical problems in mathematics for
ing: A comprehensive approach (3rd ed.). Clifton Park, health occupations (2nd ed.). Clifton Park, NY: Delmar
NY: Delmar Learning. Learning.
Physicians’ desk reference. (2009). Montvale, NJ: Thomson Slaven, E. M., Stone, S. C., & Lopez, A. A. (2006). Infectious
Healthcare. diseases. New York: McGraw-Hill.
1058 REFERENCES
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2006). Retrieved from http://www.cdc.gov/incidod/dhqp/
Brunner and Suddarth’s textbook of medical surgical gl_isolation.html
nursing (11th ed.). Philadelphia: Lippincott Williams & U.S. Department of Health and Human Services. (2009).
Wilkins. International classification of diseases. Washington,
Sormunen, C. (2003). Terminology for allied health pro- DC: U.S. Government Printing Office.
fessionals (5th ed.). Clifton Park, NY: Delmar Learning. U.S. Department of Labor. (2009). Occupational outlook
Sorrentino, S. (2006). Mosby’s essentials for nursing assis- handbook. Washington, DC: U.S. Government Printing
tants (3rd ed.). St. Louis, MO: Mosby. Office.
Spatz, A., & Balduzzi, S. (2005). Homemaker/home health Villemarie, L., & Villemarie, D. (2006). Grammar and writ-
aide (6th ed.). Clifton Park, NY: Delmar Learning. ing skills for the health care professional (2nd ed.). Clif-
Spratto, G., & Woods, A. (2008). PDR: Nurse’s drug hand- ton Park, NY: Delmar Learning.
book. Clifton Park, NY: Delmar Learning. Wallace, H. R., & Masters, A. (2006). Personal development
Stedman, T. L. (2005). Stedman’s alternative and comple- for life and work (9th ed.). Cincinnati, OH: South-West-
mentary medicine words (2nd ed.). Philadelphia: Lip- ern.
pincott Williams & Wilkins. Walter, A., Rutledge, M., Edgar, C., & Davis, R. (2004).
Stedman’s medical dictionary for the health professions First responder handbook. Clifton Park, NY: Delmar
and nursing (5th ed.). (2005). Philadelphia: Lippincott Learning.
Williams & Wilkins. Walz, B. J. (2002). Introduction to EMS systems. Clifton
Stoy, W., Platt, T., & Lejeune, D. A. (2005). Mosby’s EMT- Park, NY: Delmar Learning.
basic textbook (2nd ed.). St. Louis, MO: Mosby. Waughfield, C. (2002). Mental health concepts. Clifton
Terryberry, K. (2005). Writing for the health professions. Park, NY: Delmar Learning.
Clifton Park, NY: Delmar Learning. Weiss, R. (1999). The physical therapy aide (2nd ed.). Clif-
Thibodeau, G., & Patton, K. (2004). Structure and function ton Park, NY: Delmar Learning.
of the body (12th ed.). St. Louis, MO: Mosby. Wendleton, K. (2006). Launching the right career. Clifton
Thibodeau, G., & Patton, K. (2005). Human body in health Park, NY: Delmar Learning.
and disease (4th ed.). St. Louis, MO: Mosby. Wendleton, K. (2006). Mastering the job interview and
Thibodeau, G., & Patton, K. (2007). Anatomy and physiol- winning the money game. Clifton Park, NY: Delmar
ogy (6th ed.). St. Louis, MO: Mosby. Learning.
Thibodeaus, M. (2000). Delmar’s dental exam review. Clif- Wendleton, K. (2006). Packaging yourself: The targeted
ton Park, NY: Delmar Learning. resume. Clifton Park, NY: Delmar Learning.
Thomson Delmar Learning. (2005). Delmar learning’s Wendleton, K. (2007). The five o’clock club job search
quick reference for health care providers. Clifton Park, workbook. Clifton Park, NY: Delmar Learning.
NY: Delmar Learning. Wertz, E. (2002). Emergency care for children. Clifton Park,
Thomson Delmar Learning. (2005). Health care career NY: Delmar Learning.
exploration CD-ROM. Clifton Park, NY: Delmar Wheeler, S. Q. (2002). Telephone triage protocols (2nd ed.).
Learning. Clifton Park, NY: Delmar Learning.
Thomson Delmar Learning. (2006). Nursing assistant White, L. (2005). Foundations of basic nursing (2nd ed.).
illustrated. Clifton Park, NY: Delmar Learning. Clifton Park, NY: Delmar Learning.
Thomson Delmar Learning. (2006). Nursing assistant White, L., & Duncan, G. (2002). Medical-surgical nursing:
skills checklist. Clifton Park, NY: Delmar Learning. An integrated approach (2nd ed.). Clifton Park, NY:
Thomson Delmar Learning. (2006). Vital signs for medical Delmar Learning.
assistants interactive CD. Clifton Park, NY: Delmar Whittle, J. (2001). 911 responding for life: Case studies in
Learning. emergency care. Clifton Park, NY: Delmar Learning.
Throop, R. K., & Castellucci, M. (2006). Personal excel- Williams, S. J. (2005). Essentials of health services (3rd ed.).
lence. Clifton Park, NY: Delmar Learning. Clifton Park, NY: Delmar Learning.
Tideiksaar, R. (2006). Avoiding falls: A guideline for Williams, S. J., & Torrens, P. (2002). Introduction to
certified nursing assistants. Clifton Park, NY: Delmar health services (6th ed.). Clifton Park, NY: Delmar
Learning. Learning.
U.S. Department of Agriculture. (2005). Dietary guidelines Williams, S., & Schlenker, E. (2007). Essentials of nutrition
for Americans. Washington, DC: U.S. Government and diet therapy (9th ed.). St. Louis, MO: Mosby.
Printing Office. Wischnitzer, S., & Wischnitzer, E. (2005). Top 100 health-
U.S. Department of Agriculture. (2005). Finding your way care careers (2nd ed.). Indianapolis, IN: Jist Works.
to a healthier you. Washington, DC: U.S. Government Woelfel, J., & Scheid, R. (2001). Dental anatomy (6th ed.).
Printing Office. Philadelphia: Lippincott Williams & Wilkins.
U.S. Department of Health and Human Services. (2007) Wolfinger, A. (2007). Best career and education Web sites
Guidelines for isolation precautions in hospitals. (5th ed.). Indianapolis, IN: Jist Works.
References 1059
Woodrow, R. (2007). Essentials of pharmacology for health Zakus, S. (2001). Clinical skills for medical assistants (4th
occupations (5th ed.). Clifton Park, NY: Delmar Learn- ed.). St. Louis, MO: Mosby.
ing. Zalenski, R., & Stone, S. C. (2008). Emergency palliative
Wright, P., & Field, B. (2000). Better job search in 3 easy care. St. Louis, MO: McGraw-Hill.
steps. Clifton Park, NY: Delmar Learning. Zedlitz, R. H. (2003). How to get a job in health care. Clif-
Wright, P., & Field, B. (2000). Better job skills in 3 easy steps. ton Park, NY: Delmar Learning.
Clifton Park, NY: Delmar Learning.
Wright, P., & Field, B. (2000). Better resumes in 3 easy steps.
Clifton Park, NY: Delmar Learning.
INDEX
A Admitting
officers/clerks, 73, 74, 92
Analgesics, patient controlled (PCAs), 909
Anaphylactic shock, 480, 484, 487
Abbreviations patients, 74, 782–786 Anatomy, 140–234, 554–557
dental, 568–572 Adolescence, 242–244 Anemia, 191, 673, 677, 683, 692
medical, 120–127, 734 Adrenal gland, 217, 218, 223 Anesthesia
medical records, 991 Adulthood, 236, 238, 244–247 dental, 618–624
states, 997 Advance directives, 113–115, 249 minor surgery, 750, 753
symbols, 127, 570–572 AED, 453–454, 460–461 specialty, 51
Abdominal Aerobic organisms, 351 surgery, 750, 753, 907–908
cavity, 149, 150 Affection, 251–252 types, 618, 750
injuries, 508, 512 Against medical advice, 105, 784 Anesthesiologist, 51
quadrants, 150, 151 Agar, 656, 662–665 Aneurysm, 191
regions, 150, 151 Agency for Health Care Policy and Re- Anger, death, 247
thrusts, 457, 469–471 search (AHCPR), 31–32 Angioplasty, 192
Abrasion, 473 Agent, 107 Animal health technician, 58–60
Absorption, of nutrients, 301 Aging Anorexia, 243, 309
Abuse confusion and disorientation, 246, 277, Answering services, 980–981
chemical/drug, 30, 82–83 287–291 Anthrax, 357, 358
child, 30, 106 myths, 276–278 Antibiotic resistant, 352, 398, 656–657
domestic, 30, 106 needs, 16, 238, 247, 291–292 Antibody screen, 688
elder, 30, 106, 292 physical changes, 245–246, 278–284 Anticoagulant, 669, 672
facilities, 30 psychosocial changes, 246, 284–287 Antioxidants, 21
patient, 105–106, 292 Aide. See Assistant Antisepsis, 357, 359
Acceptance AIDS, 231, 338, 354. 355, 363 Aphasia, 89
of criticism, 85 Air compressor, 576, 581 Apical pulse, 414, 438–440
of death, 248 Air-water syringe, 577, 581–582 Aplastic anemia, 191
Accidents Airborne precautions, 399 Apnea, 202–203, 434
first aid, 449–452, 473–479 Airway pressure mask, 208 Appearance, personal, 82–84, 540
preventing, 336–342 Alcohol abuse, 82–83, 243, 305 Appendix, 207
Accounting system, 1007–1012 Alginate, 599, 602–605 Appendicitis, 208
Accreditation, 41 Alignment, 790–795 Application
Acculturation, 260 Alimentary canal, 204–207 job, 537–539
Acetone, urine, 700, 702–703 Allergic reactions, 484, 485, 487 letter of, 530–532, 536–537
Acne vulgaris, 154 Alopecia, 152 Applications, heat/cold, 954–966
Acquired Immune Deficiency Syndrome, Alphabetical filing, 970, 973–974, 975–977 Appointment
231, 338, 354, 355, 363 Alternative therapies, 19–23, 264–266 letter, 993
Acromegaly, 219 Alveoli, 198, 199, 280 scheduling, 319, 978, 983–986
Activity director, 62, 65, 67 Alzheimer’s disease, 246, 288–289 Aquathermia pad, 955, 961–963
Acupressure, 21, 266 AM care, 823–849 Aromatherapy, 21
Acupuncture, 20, 21, 266 Amalgam, 584, 587, 589, 632–637 Arrhythmia, 186, 193, 432, 453–454
Addison’s disease, 221 Amblyopia, 178 Art therapist, 63, 66, 67
Adenitis, 196 Ambulating patient, 940–954 Arterial blood, 187, 474, 668, 922
Adipose tissue, 100, 146 Amino acids, 298 Arteriosclerosis, 191, 246, 288
Administrator Amputation, 474 Artery, 187, 188
health care, 75, 76 Amyotrophic lateral sclerosis, 173 Arthritis, 160–161, 279, 692
medical records, 72–73, 75 Anaerobic organisms, 351 Asepsis, 356–357, 359
Analgesia, 618 Aspirating syringe, 618–624
Index 1061
Assault and battery, 105 Bedclothes, changing, 825–826, 840–842 smear, 682–687
Assignment sheet, xxxi, 550 Bedmaking, 812–823 typing, 70, 687–691
Assimilation, cultural, 259–260 closed, 812–817 Wright’s stain, 683, 685–687
Assistant cradle, 812, 821–823 Blood typing, 70, 687–691
dental, 46–48, 552–647 occupied, 812, 817–820 Blood vessels, 187, 188, 189, 190, 280, 323,
dietetic, 57–58 open, 812, 820–821 348, 955
education, 18, 41–42, 56–57, 781 postoperative, 913–915 Bloodborne Pathogen Standard, 338, 363
geriatric, 18, 56–57, 781 Bedpan, 859–862 BMI, 305–307, 308
home health care, 18, 56, 781 Bedsores. See pressure ulcer BMR, 302
medical, 50–52, 649–650, 715–778 Belt, transfer or gait, 940–941, 945–947 Body
medical laboratory, 69, 70, 648–714 Bias, 260–261, 542 cavities, 149, 150
medication, 56 Bibliography, 1052–1059 defenses, 356
mortuary, 54–55 Bilirubin, 700, 702–703 fluids, 338, 364
nurse, 55–57, 779–929 Binders, 909, 917–919 mass index, 305–307, 308
occupational therapy, 62, 64 Bioengineer, 77, 78, 79 mechanics, 334–336
ophthalmic, 60, 61 Biofeedback, 21, 266 planes, 148–149
pathology, 51 Biohazards, 363, 365, 368, 408 structure, 141–147
physical therapist, 62, 65, 931 Biological systems, 140–234
physician, 50–51 death, 452 Body positions
recreational therapy, 65 needs, 250–251 bed, 790–802
veterinary, 58–60 technician, 77, 78, 79 dental chair, 575–576, 580–581, 592–594
Assisted living facilities, 29, 285–286 Biomedical examination, 725–732
Associate degree, 40 engineer, 75, 76, 77 shock, 480–481, 482, 728
Asthma, 200 equipment technician, 75, 76, 77 Bone injuries, 161, 162, 498–505
Astigmatism, 178 Biotechnological engineer, 77, 78, 79 Bones, 156–163, 279–280
Atherosclerosis, 192, 288, 296 Biotechnology research and development, Bookkeeping system, 1007–1012
Athlete’s foot, 154, 353 43, 44–45, 77–79 Botanical medicine, 21
Athletic trainer, 63, 66, 67 Bioterrorism, 357–359 Botulism, 358
Attorney, Power of, 113, 114 Bird flu, 23, 354 Bradycardia, 432
Audiologist, 63, 66–67 Bite-wing radiograph (X-ray), 639–640, 644 Bradypnea, 434
Aural temperature, 415, 417, 426–427 Bladder Brain
Authorization, obtaining, 108–111, 115, training program, 283, 867 anatomy, 170–171, 281
339–340, 999–1000 urinary, 212, 213, 283 injury, 507, 510–511
Autoclave, 356–357, 371–378 Bland diet, 311 syndrome, 174, 288
Autocratic leader, 95 Bleeding, first aid, 473–479 Breasts
Automated external defibrillator, 453–454, Blindness, 89, 732–734 anatomy, 228
460–461 Block style letter, 994–999 self examination, 228–229, 230
Automated routing telephone system, 980 Blood, 138, 187–191, 474, 668–699, 700, Breathing, 199, 433–435, 453, 454–455
Autonomic nervous system, 170, 173 702–703 Bronchitis, 200–201, 280
Autopsy, 268–271 Blood and body fluid precautions. See stan- Brushing teeth
Avian flu, 23, 354 dard precautions method, 594–596
Avulsion, 474 Blood cells oral hygiene, 824, 827–828
Axillary temperature, 415, 424–425 anatomy, 188–191 Buccal cavity, 149, 150
Ayer blade, 738–739 counting, 671–672, 682 Budget, 545–547
Ayurvedic practitioner, 20 erythrocytes (red), 138, 188–189, 190, Bulimarexia, 243
671, 676, 682–683 Bulimia, 243
B leukocytes (white), 189–190, 671–672,

682–683
Bulk purchasing, 16
Bureau of Immigration Reform Act, 542
Bachelor’s degree, 40 platelets, 190–191, 682–683 Burns
Back thrombocytes, 190–191, 682–683 chemical, 490, 492
blows, 457, 471, 472 Blood film, 682–687 first aid, 488–493
supports, 335 Blood pressure, 193, 280, 414, 440–445 types, 488–489
Backrub, 825, 835–837 Blood smear, 682–687 Burs, dental, 578–579, 582–583
Bacteria, 352, 358, 700 Blood tests, 321–322, 668–699, 713 Bursitis, 161
Bandages, 475, 477–478, 519–525 cell counts, 671–672 Business
Bargaining, 247–248 computers, 321–322, 671 letters, 993–999
Bartholin’s glands, 228 differential, 682 skills, 969–1020
Barton, Clara, 9, 10, 11 erythrocyte sedimentation, 691–695
Basal metabolic rate, 302
Bases, dental, 624–632
fasting blood sugar, 695
film, 682–687 C
Bass method, 594–596 glucose, 695–699 Calcium hydroxide, 601, 627–628
Bath glucose tolerance, 695–696 Calculus, renal, 215
bed, 823, 842–847 glycohemoglobin, 696 Calorie
Sitz, 955, 965–966 hematocrit, 671–676 controlled diet, 311
tub, 823, 847–849 hemoglobin, 138, 189, 676–682 definition, 302–305, 307–309
waterless, 823–824 microhematocrit, 671–676 CAM therapies, 19–23, 264–266
Battery, 105 quick stain, 683, 686 Cancer
Bed bath, 823, 842–847 skin puncture, 668–671 brain, 776
1062 INDEX
Cancer (continued) Cerebrovascular accident (CVA), 174, Cleansing enemas, 889–896

breast, 228–229, 230 513–514, 517 Clinical engineer, 75, 76, 77
cervical, 229 Certification, 40–41, 554, 649, 716 Clinical laboratory
Hodgin’s disease, 196 Cervical assistant, 69, 70, 649–714
liver, 928 cancer, 229 technician, 69, 70, 72, 649–714
lung, 201, 202 spatula, 738–739 technologist, 68, 70, 72
lymphatic, 196 CEUs, 41, 325 Clinical Laboratory Improvement Amend-
ovarian, 229–230 Chain ment (CLIA), 649–650
prostatic, 226 of command, 35–37 Clinics, 29
skin, 154–155 of infection, 355–356 Clock, 24 hour, 1029
testicular, 226 Chair Closed
uterus, 229 dental, 575–576, 580–581, 592–594 bed, 812–817
Canes, 280, 943–944, 950–952 sitz, 965–966 wound, 473–474
Cannula, oxygen, 920 transfer to, 790–793, 803–806 Clothing
Capillaries, 187, 194 CHAMPUS, 34 health worker, 83
Capillary blood, 187, 474, 668–671 Characteristics, personal, 85–86 patient, 286, 825–826, 840–842
Carbohydrate Charge slips, 1008 Clotting, blood, 190–191, 669, 672
digestion, 203–208, 301 Charting Coding insurance, 1000–1003
function, 297 admission, 74, 92, 782–786 Cognitive development, 236–247
Carbon monoxide, 483, 487 errors, 92, 107, 989, 1009 Cold
Carboxylate, 601, 629–630 Federation Dentaire International (FDI) applications, 499, 954–958, 963–964
Cardiac System, 561–562, 564–565 exposure, 496–498
compressions, 455–456, 459–460, intake and output, 849–854 first aid, 496–498
462–463, 465, 467–468 medical records, 72–75, 91–92, 107–108, Colitis, 210
muscle, 164, 184, 280 972–973, 987–993 Colon, 205, 206–207
shock, 480 teeth conditions, 568–573 Color blindness, 733–734, 736
Cardiopulmonary resuscitation, 452–473 teeth surfaces, 568–573 Color-coded indexing, 971–972
Cardiovascular temperature, pulse, respiration, Colostomy, 872–876
system, 183–193, 280 418–419, 435–437 Coma, diabetic, 222, 515–516, 518
technologist, 68, 69, 72 Universal/National Numbering System, Communicable diseases, 397–409
Career passport, 535–536 560–561, 563 Communication
Careers, health care, 38–80, 554, 649–650, Checkpoints, explanation of, xxxi, 551 barriers, 89–91, 260–261, 262–263
716–717, 781, 931, 1022–1025 Checks, 1013, 1015–1016 careers, 72–75
Caries, dental, 570, 594, 632 Chemical electronic (e-mail), 326, 981
Carpal tunnel syndrome, 173 abuse, 82–83, 243 interruptions, 87–88
Carpules, anesthetic, 618–624 burns, 490, 492 language differences, 90, 262–263,
Carson, Benjamin, 14 disinfection, 357, 379, 381 989–991
Cartilage, 146, 158 injuries, 483–484, 486–487 non-English speaking, 87, 90, 262–263,
Cataract, 179, 281 Material Safety Data Sheets (MSDSs), 989–991
Catheter 236–239 nonverbal, 88, 262–263
condom, 864–865 restraints, 900 privileged, 107, 108–110
oxygen, 920 Chest process, 86–88
urinary, 851, 864–872 cavity, 149, 150 services, 43, 44–45
urine specimen, 866–867, 878 circumference, 717–719, 724–725 skills, 86–92
Caution, explanation of, xxxi, 551 compressions, 455–456, 459–460, verbal, 86–88
Cavity 462–463, 465, 467–468 written, 91–92
body, 149, 150, 197 injuries, 507–508, 511–512 Compensation, 254
dental, 570, 594, 632 Cheyne-Stokes respirations, 434 Competence, 85
CDC, 31, 358–359, 364, 398 Child Complementary therapies, 19–23, 264–266
Cell choking, 457, 469–471 Complete bed bath, 823, 842–847
reproduction, 144–145 CPR, 456, 467–468 Composite, 584, 587, 589, 634, 637–639
stem, 117, 145, 646 growth and development, 238, 240–242 Compress, moist, 954–955, 963–964
structure, 142–145, 147 Chinese medicine, 3, 20, 265 Compressions, cardiac, 455–456, 459–460,
Cellular Chiropractic, 20, 50, 266 462–463, 465, 467–468
respiration, 200 Chlamydia, 231 Computer, 107–108, 314–332, 972–973,
telephone, 981 Choking victim, 457, 469–473, 856 1004, 1009–1010
Cellulose, 297 Cholecystitis, 208 applications, 319–326, 972–973, 985,
Celsius temperature, 413–414, 415, Cholesterol 1004, 1009–1010
1027–1028 definition, 298, 348 assisted instruction, 324
Cements, dental, 624–632 diet, 311 back-up system, 321, 329, 973
Centers for Disease Control and Preven- Chronic obstructive pulmonary disease components, 316–318
tion, 31, 358–359, 364, 398 (COPD), 201 confidentiality, 107–108, 321, 329–331,
Centigrade temperature, 413–414, 415 Cilia, 197–198 973
Central nervous system, 169–172 Circulation, checking, 453, 455, 501, firewall, 329
Central/sterile supply technician, 75, 76, 504–505 history, 316
320 Circulatory system, 146, 147, 183–193, 280 Internet, 326–329
Cerebral palsy, 174 Cirrhosis, 208 literacy, 315, 536
Cerebrospinal fluid, 171, 174–175, 364 Clean catch urine specimen, 877–878,
882–884
Index 1063
protection and security, 329–331, obtaining, 656–660 restoratives, 570, 572, 584, 587, 589,
972–973 slides, 656–657, 660–661, 664–665 632–639
viruses, 329 transfers, 656–658, 660–665 skills, 552–647
Computerized tomography (CT), 71, 174, Curing light, 625, 634, 639 specialties, 46
322–323 Current Procedural Terminology (CPT) surfaces of tooth, 565–567, 594–595
Concentrator, oxygen, 921 codes, 1000–1003 symbols, 570–572
Conditions, teeth, 568–573 Cushing’s syndrome, 221, 222 trays, 584–591
Condom catheter, 864–865 Cuspidor, 578 Universal/National Numbering System,
Confidential information, 34–35, 92, Custom trays, 615–617 560–561, 563, 568–570
107–108, 111–112, 116, 321, 329–331, Cuvette, 677, 680–682, 696–697, 698 X-rays, 568, 639–645
981–982, 989 Cyanosis, 154, 434, 479 Dentist, 29, 46, 47
Confusion, 246, 277, 287–291 Cystitis, 213, 668 Denture care, 824, 828–830
Congestive heart failure, 192 Deoxyribonucleic acid (DNA), 11, 12
Conjunctivitis, 179
Connective tissue, 145–146 D Department of Health and Human Ser-
vices (USDHHS), 31
Consent, obtaining patient, 92, 105, Dance therapist, 63, 66, 67 Dependability, 85
108–110, 116, 340, 451, 750, 999–1000 Dangling, 792, 801–802 Deposit slips, 1014, 1017–1018
Conservation, energy, 16–17 Data sheet, 987, 988, 991–992 Depression, 248
Constipation, 208 Databases, 319, 970, 987, 989, 991–992 Dermatitis, 155
Contact Daydreaming, 254 Designation of Health Care Surrogate, 113,
poisoning, 483–484, 486–487 Daysheet, 1007–1012 114
precautions, 401–402 Deafness, 74, 75, 89, 180–181 Developing radiographs (X-rays), 639–643
Continuing education units (CEUs), 41, Death Development, human, 236–247
325 cultural beliefs, 268–271 Diabetes
Contracts, 106–107 post-mortem care, 925–927 first aid, 515–519
Contracture, 165, 791–792, 932 religious beliefs, 268–271 insipidus, 219
Convulsions, 174, 514, 518 stages, 247–250 mellitus, 222–223, 526, 695–696
Coronal plane, 148, 149 types, 452 Diabetic
Coronary Deciduous teeth, 554–557, 558–560 blood tests, 695–699
occlusion, 192, 193, 513, 517 Decubitus ulcer, 790–791 coma, 222, 515–516, 518
stent, 192 Defamation, 106 diet, 222, 310
Correspondence. See Letters Defense mechanisms, 253–255 Diagnosis codes, 1000–1003
Cost containment,15–17 Defibrillator, 48, 186, 453–454, 460–461 Diagnostic
Counseling centers, 30–31 Deficit pulse, 438–439 careers, 44–45, 67–72
Counselor, genetic, 52–54 Dehydration, 145, 849 cluster standards, 43, 44–45
Cover letter, 530–532, 536–537 Delirium, 288 computers, 319, 321–324
Cowper’s gland, 225 Dementia, 288 related groups (DRGs), 16
CPAP mask, 203 Democratic leader, 95 services, 67–72
CPR, 452–473 Denial vascular technologist, 68, 69
CPT codes, 1000–1003 death, 246 Dialysis, 66
Cradle, bed, 812, 821–823 defense mechanism, 254–255 Dialysis technician, 63, 66
Cranial cavity, 149, 150 Dental Diaphoresis, 479
Cranium, 157–158 abbreviations, 568–569, 572 Diarrhea, 208–209
Cremation, beliefs, 268–271 anesthesia, 618–624 Diastole, 185
Cretinism, 220 assistant, 46–48, 552–647 Diastolic pressure, 440, 441
Crick, Francis, 11, 12 bases, 624–632 Diet, 295–313
Cross index/references, 971 brushing, 594–596, 824, 827–828 balanced, 82, 302–305
Crossmatch blood, 687–688 careers, 46–48, 554 bland, 311
Crutches, 941–943, 947–950 carts, 577–579, 581–583 calorie-controlled, 311
Cryotherapy, 954–958, 963–964 cements, 624–632 diabetic, 310
CT, 71, 174, 322–323 chair, 575–576, 580–581, 592–594 fat-restricted, 311
Cultural diversity, 90–91, 258–274, 291, conditions, 568–573, 594 feeding patient, 855–858
305, 989–991 custom tray, 615–617 fiber, 283, 311
communication barrier, 90, 260–261 equipment, 574–583 five major food groups, 82, 302–305
eye contact, 90, 264 Federation Dentaire International (FDI) liquid, 310
family organization, 261–262 System, 561–562, 564–565 low-cholesterol, 311
gestures, 264 flossing, 594–595, 597–598, 824, 827–829 low-residue, 311
health beliefs 90, 264–267, 989–991 handpieces, 577–579, 581–583 macrobiotic, 22
language, 90, 262–263, 989–991 hygienist, 46–48 personal, 82, 302–305
personal space, 263–264 impressions, 598–608 protein, 283, 311
religion, 267–272 instruments, 584–591 regular, 310
respecting, 90–91, 272, 989–991 laboratories, 30 religious restrictions, 305, 306
touch, 91 laboratory technician, 46–48 requirements, 302–305
Culture light, 575, 580, 592–594 sodium-restricted, 311
beliefs, 258–274, 291, 305 models, 598–601, 608–614 soft, 310
characteristics, 258, 291 offices, 29, 574 therapeutic, 266, 309–312
Cultures, 656–667 oral hygiene, 594–598, 824, 827–832 weight management, 100, 305–309
agar, 656, 662–665 radiographs, 568, 639–645 Dietary services, 57–58
Gram’s stain, 657, 666–667
1064 INDEX
Dietetic sterile, 389–392 Emotional

assistant, 57–58 surgical, 908–909 development, 236–247
technician, 57–58 tape application, 396, 397 wellness, 18–19
Dietitian, 57–58, 320 tray, 385–386, 389–392 Empathy, 85
Differential count, 682 types, 519–520 Emphysema, 201, 280
Digestion, 203–208, 301 DRGs, 16 Employability skills, 528–549
Digestive system, 146, 147, 203–210, Drop technique, 385–386, 387–388 Employment Eligibility Verification Form,
282–283, 301 Droplet precautions, 399–401 542
Direct smear, 656, 660–661 Drug Encephalitis, 174
Directives, advance, 113–115 abuse, 82–83, 243 Endocrine system, 146, 147, 216–223,
Disability administering, 770–773 283–284
legal, 106 natural sources, 36 Endodontics, 46
physical, 89, 90–91, 286–287 Physician’s Desk Reference (PDR), Endogenous infection, 355
Discharging patients, 782–784, 788–789 768–770 Endometriosis, 229
Discretion, 85 resistant organisms, 352, 398, 656–657 Enema, 889–898
Diseases Dry heat sterilization, 373 disposable, 889, 894–896
aging, 246, 279, 280, 281, 286–287, Durable Power of Attorney, 113, 114 normal saline, 889–894
288–289 Durelon, 601, 629–630 oil retention, 889, 896–898
bones, 160–163, 279, 296 Dwarfism, 219, 220 soap solution, 889–894
circulatory, 191–193, 280, 296 Dycal, 601, 627–628 tap water, 889–894
communicable, 397–409 Dying, stages of, 247–250 Energy conservation 16–17
cultural beliefs, 90–91, 265–266 Dysphagia, 282–283, 855–856 Engineer
digestive, 208–210, 282–283, 296–297 Dyspnea, 280–281, 434 biomedical (clinical), 75, 76, 77
ear, 180–181, 281–282 biotechnological, 77, 78, 79
endocrine, 219–223, 695
eye, 178–179, 281 E English measurements, 775–776, 1027–1028
Enteral feedings, 849–850
heart, 191–193 Ear Enthusiasm, 85
hemolytic, 688 anatomy, 180, 281–282 Entrepreneur, 42–43
integumentary, 154–156 diseases, 180–181 Environmental services
International Classification of, examination, 737, 740, 741–742 careers, 75–77, 320
1000–1003 injuries, 506–507, 510 cluster standards, 43, 44–45
lymphatic, 196 Ear, eye, nose, throat (EENT) examination, Enzymes, digestive, 205–206, 301
muscular, 165–168, 279–280 737, 741–742 Epidemic, 397
nervous, 173–176, 281–282 Early adulthood, 238, 244–245 Epidemiologist, 73, 74, 75
pathophysiology, definition,142 Early childhood, 238, 240–241 Epididymitis, 226
reproductive, 226, 228–230 Earthquake safety, 345 Epiglottis, 198, 199
respiratory, 200–203, 280–281 Eating disorders, 242–243 Epilepsy, 174
sexually transmitted, 230–233 Ebola, 24, 354, 358 Epistaxis, 201–202, 507, 511
skeletal, 160–163, 279, 296 Echocardiograph, 69, 322 Epithelial tissue, 145
skin, 154–156 Eczema, 155 Equipment
urinary, 213–216, 283 Edema, 145, 849 biomedical, 75, 76, 77
Disinfection, chemical, 357, 379–381 Educational requirements, 40–42 dental, 574–583
Disk, ruptured, 163 Elastic personal protective, 338, 363, 365,
Dislocation, 161, 498–499, 503 bandages, 519–520 366–367, 369–370, 398, 574
Disorientation, 246, 277, 287–291 hose, 909, 915–916 physical examination, 738–739, 741,
Displacement, 254 Elderly 743, 745, 746
Disposable care, 275–294 safety, 338–339
enema, 889, 894–896 confusion and disorientation, 246, 277, Ergonomics, 338–342
thermometer, 418 287–291 Erikson’s stages of psychosocial develop-
Diverticulitis, 209 myths, 276–278 ment, 237, 238
DNA, 11, 12 needs, 16, 238, 247, 291–292 Errors, 92, 107, 989, 1009
Doctor physical changes, 245–246, 278–284 Erythema, 153
degree, 40 psychosocial changes, 246, 284–287 Erythrocyte
dental, 29, 46, 47, 554 Electrocardiogram, 186, 322, 740, 756–768 anatomy, 188–189, 190, 676
eye, 60–61 Electrocardiograph technician, 68–69 count, 671
medical, 50–52, 716–717 Electroencephalographic technologist, microhematocrit, 671–676
psychiatric, 51, 52–54 68, 69 sedimentation rate, 691–695
Dorsal Electroneurodiagnostic technologist, 68, urine, 700, 710
cavity, 149, 150 69 Esophagus, 205–206, 301
recumbent position, 728, 730–731 Electronic Esteem, 252
Drainage mail, 326, 981 Ethics, 111–112
irrigation, 851 thermometers, 417, 428–429 Ethnic groups, 258–259
surgical, 909 Embalmer, 54–55 Ethnicity, 258–259
urinary, 851, 864–872 Embolus, 192 Eustachian tube, 180
Dressings Emergency medical Evacuator, oral, 576–577, 581
application, 389–392, 520–521 paramedic, 48–49 Evaluation sheet, xxxi, 551
bandages, 519–525 services, 30, 48–49, 449–452 Examination
first aid, 519–521 technician, 48–49 breast self, 228–229, 230
Index 1065
ear, eye, nose, throat (EENT), 737, First aid, 448–527 Forms
741–742 abdominal injury, 508, 512 admission, 782–784
gynecological, 737, 743–745 bandages, 475, 519–525 financial, 1007–1012
physical, 737–747, 987 bleeding, 473–479 job application, 537–539
positions, 725–732 bone injury, 161, 498–505 insurance, 999–1006, 1008–1009
testicular self, 226 burn, 488–493 intake and output, 849–854
Excretory system, 146, 147, 210–216, 283 cardiopulmonary resuscitation, 452–473 medical, 987–993
Exercises cerebrovascular accident, 174, 513–514, Fowler’s position, 727, 730
benefits, 82, 280, 302, 307–309 517 Fracture bedpan, 859
range of motion, 280, 932–940 chest injuries, 507–508, 511–512 Fractures, 161, 162, 498–505
Exogenous infection, 355 choking, 457, 469–473 Frontal plane, 148, 149
Expiration, 199, 433 cold exposure, 496–498 Frostbite, 496–498
Expressed contracts, 106 convulsion, 514, 518 Full mouth radiographs (X-rays), 640,
Extended care facility, 28–29 diabetic reactions, 515–516, 518–519 644–645
External respiration, 199–200 dislocation, 161 Funeral director, 54–55
Extinguisher, fire, 343–347 dressings, 519–525 Fungi, 353
Extracorporeal circulation technologist, ear injury, 506–507, 510
Eye
63, 66, 67 emergency medical services, 30, 48–49,
449–452 G
anatomy, 177–178, 1020 epistaxis, 201–202, 507, 511 Gait belt, 940–941, 945–947
cavity, 149, 150 eye injury, 490, 492, 505–506, 509–510 Gaits
changes in aging, 281 fainting, 514, 518 canes, 943–944, 950–952
contact, 90, 264, 540 fracture, 161, 162, 498–505 crutches, 941–943, 947–950
diseases, 178–179, 281, 1020 frostbite, 496–498 Gallbladder, 207, 208, 301
examination, 737, 739, 741–742 genital injury, 509, 512 Gastroenteritis, 209
injuries, 341, 490, 505–506, 509–510 head injury, 507, 510–511 Gastrointestinal system, 203–210, 282–283,
irrigation, 490, 492 heart attack, 193, 513, 517 301
protection, 177–178, 365, 366–367, 370, heat exposure, 493–495 Gastrostomy tube, 849–850
574, 634 illness, 513–519 Genes, 142, 348, 548, 928
vision screening, 732–736 injury, 473–479, 498–512 Genetic counseling, 30–31, 53–54
insect bite, 484, 487 Genital injury, 509, 512
F joint injury, 498–505
moving victim, 450, 451–452, 454
Genome, 142
Geographic filing, 971
Face shields, 365, 366–367 nosebleed, 201–202, 507, 511 Geriatric
Facilities, health care, 26–31 obstructed airway, 457, 469–473 assistant, 18, 56–57, 781
Fahrenheit temperatures, 413–414, 415, poisoning, 483–488 care, 17–18, 275–294
1027–1028 priorities of care, 449–452 confusion and disorientation, 246, 277,
Fainting, 514, 518 shock, 479–482 287–291
Fallopian tubes, 227, 228 snakebite, 484, 487 facilities, 28–29, 276–277
False imprisonment, 105 spine injury, 480, 502 late adulthood, 245–247, 275–294
Family organization, 261–262 stroke, 174, 494, 495, 513–514, 517 myths, 276–278
Fascia, 165 tick, 484, 487 needs, 16, 238, 247, 291–292
Fasting blood sugar, 695 triage, 451 physical changes, 245–246, 278–284
Fats wounds, 473–479 psychosocial changes, 246, 284–287
digestion, 205–206, 301 First responder, 48–49 Geriatrician, 51
function, 297–298 Flossing teeth, 594–595, 597–598, 824, Gerontology, 276
restricted-diet, 305, 311 827–828 Gestures, 264
tissue, 100 Flu, 23–24, 202, 353–354 Giantism, 219
Fax machine, 981–982 Flukes, 354–355 Gingiva, 556, 557, 586
FDA, 24, 31, 358, 776 Foley catheter, 864–865 Gland
Federation Dentaire International (FDI) Food Bartholin’s, 228
System, 561–562, 564–565 digestion, 203–208 Cowper’s, 225
Feeding feeding patient, 855–858 endocrine, 146, 147, 216–223, 283–284
patient, 855–858 groups, 302–305 lacrimal, 177
tube, 849–850 isolation transfer, 407–408 lymph, 194–195
Female reproductive, 227–230 My pyramid, 302–305 prostate, 225, 283
Fever, 416 nutrition, 295–313 salivary, 205, 301
Fibromyalgia, 165–166 religious restrictions, 305, 306 sebaceous, 152, 154
Filing records, 970–977 service workers, 57–58 sudoriferous, 152, 153
Film Food and Drug Administration (FDA), 24, Glaucoma, 179, 281
blood, 682–687 31, 358, 776 Glioma, 776
radiograph (X-ray), 639–645 Foot drop, 165, 791–792, 932 Glomerulonephritis, 214
Filoviruses 24, 354, 358 Forceps, transfer, 385–386, 388 Glossary, 1030–1051
Financial records, 319, 1007–1019 Forensic Gloves
Finger puncture, 668–671 medicine, 77–79, 687 donning and removing, 366, 369,
Fire safety, 343–347 scientist, 77–78, 79 392–394
Firewall, 329 technicians, 77, 79 infection control, 365, 366, 369
1066 INDEX
Gloves (continued) geriatric, 17–18, 56–57 Hippocrates, 4, 5

isolation, 403–406 history of, 2–14 History
sterile, 392–394 holistic, 19, 92, 261 computer, 316
Glucose home, 17, 30 health care, 2–14
blood, 695–699 hospice, 30, 248–249 physical forms, 987–993
fasting blood sugar, 695 industrial, 31 Hives, 487
glycohemoglobin, 696 insurance, 23, 32–35, 999–1006, HMOs, 31, 33, 34
meter, 695–699 1008–1009 Hodgkin’s disease, 196
tolerance test, 695–696 integrative, 19 Holistic health care, 19, 92, 261
urine, 695, 700, 702–703 legal directives, 113–115, 249 Holter monitoring, 322
Glycosuria, 695 national plan, 23 Home health care, 17, 30, 56–57
Goals, 98–99 Policy and Research Agency, 31–32 agencies, 30
Goiter, 220 power of attorney (POA), 113, 114 assistant, 55–57, 781
Gonorrhea, 231–232 records, 72–75, 91–92, 107–108, 972–973, Homeopaths, 20, 21
Government 987–993 Homeostasis, 211, 414
agencies, 20, 31–32 religious beliefs, 268–271 Honesty, 85
hospitals, 28 school, 31 Horizontal recumbent position, 726, 729
Gown skill standards, 43, 44–45, 1026 Hormones, 216–223
changing, 825–826, 840–842 surrogate, 113, 114 HOSA, 1022–1023
infection control, 365, 366, 369–370, 574 systems, 26–31 Hose, surgical, 909, 915–916
isolation, 403–406 trends, 14–25 Hospice, 30, 248–249
Gram’s stain, 657, 666–667 Health Insurance Portability and Ac- Hospital, 27–28, 35, 315, 319–321, 406–409
Graphing countability Act (HIPAA), 34–35, Household measurements, 775–776,
growth, 717, 718 92, 108–110, 321, 329–331, 970–971, 1027–1028
National Center for Health Statistics, 999–1000 Housekeeping worker, 75, 76, 93
717, 718 Health Occupations Students of America HSTE, 40, 46
TPR, 435–437 (HOSA), 1022–1023 Human
Grave’s disease, 220 Health science technology education anatomy and physiology, 140–234
Groin temperature, 415 (HSTE), 40, 46 growth and development, 235–256
Gross income, 543–545 Hearing needs, 250–255
Growth and development, 235–256, 717, aid, 89, 181, 281–282 Hurricane safety, 345
718 loss, 74, 75, 89, 180–181, 281–282 Hydrocephalus, 174–175, 717
Growth graph, 717, 718 Heart Hydrotherapy, 21
Gynecological examination, 737, 743–745 anatomy, 183–187 Hygiene
Gynecologist, 51 attack, 193, 513, 517 health worker, 84
changes in aging, 280 oral, 824, 827–832
H congestive failure, 192

echocardiograph, 69, 322
patient, 823–849
Hygienist, dental, 46–47, 48
Hair electrical pathway, 186–187, 756–760 Hyperglycemia, 222, 515–519, 695
anatomy, 152 electrocardiogram, 186, 322, 756–768 Hyperopia, 178, 179, 734
care, 824–825, 832–833 sounds, 185, 438 Hyperparathyroidism, 221
standards for health workers, 84 stress test, 322 Hypertension, 193, 296, 441
Handpieces, dental, 577–579, 581–583 surgery, 66, 192 Hyperthermia, 416
Handwashing, 359–362, 365, 366 Heat Hyperthyroidism, 220
Hantaviruses, 23–24, 354 applications, 499, 954–956, 959–966 Hypnotherapy, 22, 266
Head cramps, 493,494–495 Hypnotist, 20
circumference, 717–719, 724 exhaustion, 493, 495 Hypoglycemia, 515–519, 695
injuries, 507, 510–511 sterilization, 373 Hypoparathyroidism, 221
Healing touch, 21 stroke, 494 Hypoperfusion, 479–482
Health Height, 717–725 Hypotension, 441
department, 29, 31–32 Helminths, 354–355 Hypothermia, 279, 416, 496–498, 954–955
informatics, 43, 44–45, 72–75, 319–320 Hematocrit, 671–676 Hypothyroidism, 220
insurance, 32–35, 999–1006 Hemiplegia, 174, 175, 287, 943
maintenance organizations, 31, 33, 34
science technology education (HSTE),
Hemoccult slide, 879–880, 887–888
Hemodialysis machine, 214, 215 I
40, 46 Hemoglobin, 138, 189, 676–682 I & O records, 849–854
unit coordinator, 73, 74 Hemolytic disease, 688 ICD-9-CM codes, 1000–1003
Health care Hemophilia, 193, 526 Ice bag/collar, 954, 957–958
administrator, 75, 76 Hemorrhage, 479, 480 Icons, xxxi, 551
advance directives, 113–115, 249 Hemorrhagic fever, 24, 354, 358 Identifying patient, 115–116, 340
alternative therapies, 19–23, 264–266 Hemorrhoids, 209 Identifying teeth
careers, 38–80, 554, 649–650, 716–717, Hemovac, 851 conditions, 568–573
781, 931, 1022–1025 Hepatitis, 209, 338, 354, 363, 692 Federation Dentaire International (FDI)
complementary therapies, 19–23, Herbal medicine, 21 System, 561–562, 564
264–266 Hernia, 209, 210 names, 558–560
core standards, 43, 44–45, 1026 Herpes, 175–176, 232, 353 surfaces, 565–567, 594–595
cultural beliefs, 90–91, 264–267 High-speed handpiece, 579, 583 Universal/National Numbering System,
designation of surrogate, 113, 114 HIPAA, 34–35, 92, 108–110, 321, 329–331, 560–561, 563, 568–570
facilities, 26–31 970–971, 999–1000 Ileostomy, 872
Index 1067
Illness
cultural beliefs, 90–91, 265–266, 989–991
ultrasonic cleaning, 381–384
wrapping for autoclave, 371–377 K
first aid, 513–519 Insulin Ketones, urine, 700, 702–703
needs, 250–252 function, 218, 221–222, 526, 695 Key terms
religious beliefs, 267–272 shock, 515–516, 518–519, 695 anatomy and physiology 141
terminal, 90–91, 247 Insurance business and accounting skills, 970
Illustrator, medical, 73, 74, 75 forms, 999–1006 careers in health care, 39–40
Imagery, 22, 97, 266 health, 23, 32–35, 999–1006, 1008–1009 computer technology in health care, 315
Imaging, radiologic, 70–71, 321–324 liability, 116 cultural diversity, 258
Impaction, 889 State Children’s Health Program, 33–34 dental assistant skills, 553
Impetigo, 155 Intake and output records, 849–854 first aid, 449
Implied contracts, 106 Integrative health care, 19 geriatric care, 276
Impressions, dental, 598–608 Integumentary system, 146, 147, 151–156, health care systems, 27
alginate, 599, 602–605 279 history and trends of health care, 3
polysulfide, 599–600, 605–608 Internal respiration, 199–200 human growth and development, 236
rubber base, 599–600, 605–608 International Classification of Diseases infection control, 351
silicones, 600–601 (ICD), 1000–1003 laboratory assistant skills, 649
Imprisonment, false, 105 Internet, 325–331 legal and ethical responsibilities, 104
Incision, 473 Internet searches, 25, 37, 80, 101, 118, 138, medical assistant skills, 716
Income, 543–545 233, 256, 273–274, 331, 348–349, 411, medical terminology, 120
Incontinence, 213, 283, 867 446–447, 526, 548–549, 647, 714, 777, nurse assistant skills, 780
Independence, elderly, 276–277, 285–286 929, 967–968, 1020–1021 nutrition and diets, 296
Independent living facilities, 29, 285–286 Interpreter, 73, 74, 75, 262–263, 293–294, personal and professional qualities of a
Industrial health care centers, 31 313 health care worker, 82
Infant Interview, job, 539–543 physical therapy skills, 931
cardiopulmonary resuscitation, 456, Intestine, 205, 206–207, 301 preparing for the world of work, 529
464–466 Intravenous (IV), 364, 771, 850–851 safety, 334
chest circumference, 717–719, 724–725 Invasion of privacy, 105 vital signs, 413
choking, 457, 471–473 Inventory Kidney, 211, 212, 213, 283
growth and development, 237–240 personal list, 782–789 Kilocalorie, 302–305, 307–309
head circumference, 717–719, 724 supplies, 319 Knee-chest position, 726–727, 730
height and weight, 723–725 Ionization therapy, 22 Kubler-Ross, Elizabeth, 247–248
Infection IRM, 625, 630–632 Kyphosis, 163
chain of, 355–356 Iron-deficiency anemia, 191
control, 350–411
respiratory, 203
Irrigation
enema, 889–898 L
wound, 473, 476, 478 eye, 490, 492 Laboratory
Infectious-waste bags, 365, 368, 370, nasogastric tube, 850–851 careers, 68, 69–70, 72, 320, 649–650
406–409 Ishihara method, 733–734, 736 dental, 30, 46–48
Influenza, 23–24, 202, 353–354 Isolation, 397–409 facilities, 30
Informatics Improvement Amendment, 649–650
careers, 72–75
section, xxxi, 550 J medical, 30, 320, 648–714
ophthalmic, 60–61
services cluster standards, 43, 44–45 Jacket restraint, 901, 904–906 skills, 648–714
systems, 43, 44–45, 72–75, 319–321 Jackknife position, 728–729, 731–732 waived tests, 649–650
Informed consent, 105 Jaeger system, 733, 735–736 Laceration, 474
Ingestion poisoning, 483, 486 Jaundice, 153 Lacrimal gland, 177
Inhalation Jewelry Laennec, Rene, 8, 9
medication, 771 health worker, 84 Laissez-faire leader, 95
oxygen, 199–200, 919–924 postmortem, care of, 925, 927 Language
poison, 483, 487 surgery, care of, 907, 912 barriers, 86–91, 262–263
Injection valuables, care of, 782, 785, 787, 789, differences, 90, 262–263, 989–991
poisoning, 484, 485 907, 912, 925, 927 therapist, 63, 66, 67
types, 771, 772 Job, 529–549 Large intestine, 205, 206–207, 301
Injury application, 537–539 Laryngitis, 202
first aid, 473–479, 488–493, 498–512 career passport, 535–536 Larynx, 198–199, 280, 738
preventing, 282, 336–342 cover letter, 531, 532, 536–537 Late adulthood, 238, 245–247
reporting, 341, 364, 368 income, 543–545 Late childhood, 238, 241–242
Insect bites, 484, 487 interview, 539–543 Law
Inspiration, 199, 433 keeping skills, 529–530, 536 civil, 104–106
Instruments resume, 531–537 criminal, 104
chemical disinfection, 357, 379–381 sources, 530–531 Laws
dental, 584–591 Joint Bioterrorism Act, 359
minor surgery, 748–751 anatomy, 160 Bloodborne Pathogen Standard, 338,
physical examination, 737–747 injuries, 498–505 363
sterilization, 356–357, 371–379 movements, 164–165, 166 Bureau of Immigration Reform Act, 542
suture removal, 750, 751, 755–756 range of motion, 166, 932–940 Clinical Laboratory Improvement
types, 160 Amendment, 649–650
1068 INDEX
Laws (continued) Living will, 113, 114 Medicaid, 33

Health Insurance Portability and Ac- Long-term care Medical
countability Act (HIPAA), 34–35, facilities, 28–29, 284, 285–286 abbreviations, 120–127
92, 108–110, 321, 329–331, 970–971, training programs, 18, 56–57 assistant, 50–52, 715–778
999–1000 workers, 18, 56–57 careers, 50–52, 716–717
Needlestick Safety and Prevention Act, Lordosis, 163 centers, 29
363–364 Lou Gehrig’s disease, 173 doctor, 50–52
Occupational Exposure to Hazardous Love, 251–252 emergency services, 30, 48–49
Chemicals Standard, 336–338 Low-calorie diet, 311 illustrator, 73, 74, 75
Older Americans Act, 292 Low-cholesterol diet, 311 interpreter, 73, 74, 75
Omnibus Budget Reconciliation Act, 18 Low-residue diet, 311 laboratories, 30, 68–70
Patient Self-Determination Act (PSDA), Low-speed handpiece, 578–579, 582–583 laboratory assistant, 69, 70, 72, 648–714
113–115 Lung laboratory technician, 69, 70, 72, 320,
Patient’s Bill of Rights, 112–113 anatomy, 185, 198, 199 648–714
Standards for Privacy of Individu- cancer, 201, 202 laboratory technologist, 68, 70
ally Identifiable Health Information, Lymphangitis, 196 librarian, 73, 74, 75
108–110, 321, 329–331 Lymphatic, system, 146, 147, 194–196 offices, 29, 35–36
Leadership, 93, 94–95, 536 scientist, 77–78, 79
Leads, ECG, 758–760, 763–765
Ledger M skills, 648–714, 715–778
specialties, 51
appointment, 983–986 Macrobiotic diet, 22 symbols, 127
card, 1008 Macular degeneration, 179, 1020 terminology, 87, 119–139
financial, 1007–1112 Maggots, 24 transcriptionist, 73, 74
Leeches, 24 Magnetic resonance imaging (MRI), 71, translator, 73, 74, 75
Left lateral position, 726, 729–730 323 Medical records
Legal Makeup, health worker, 84 administrator, 72–73, 75
directives, 113–115, 249 Male reproductive, 224–226 careers, 72–75
disability, 106 Malnutrition, 296–297 completing, 91–92, 319, 987–993
responsibilities, 46, 94, 103–111, 116, Malpractice, 104–105 confidentiality, 107–108, 319, 989
972, 989 Mammogram, 71 errors, 92, 107, 989, 1009
Letter Managed care, 34 filing, 970–977
cover, 530–532, 536–537 Mandibular storage, 972–973
business, 993–999 block, 618 technician, 73–74, 75
Leukemia, 193, 683 bone, 158, 160, 558 Medical terminology, 119–139
Leukocyte teeth, 558–560 Medicare, 33
anatomy, 189–190 Marburg virus, 24, 354, 358 Medication aide, 55–57
count, 189–190, 671–672, 682 Mask Medications
types, 190, 682 continuous airway pressure, 203 botanical, 21, 36
urine, 700, 710 infection control, 365, 366–367, 370, 574 dental anesthesia, 568–572
Liability insurance, 116 isolation, 399, 400, 403–406 disposal of, 772–773
Libel, 106 oxygen, 919–920 herbal, 21
Librarian, medical, 73, 74, 75 resuscitation, 365, 368, 370, 453 math, 773–776
Lice, 232 Maslow’s hierarchy of needs, 250–252 nature, 36
Licensed Practical Nurse (LPN), 55–57 Mass purchasing, 16 Physician’s Desk Reference (PDR),
Licensed Vocational Nurse (LVN), 55–57 Massage 768–770
Licensure, 41 back, 825, 835–837 transdermal, 771–772
Life stages, 236–247 Swedish, 23 types, 770–772, 890
Ligament, 146, 160, 556, 557 therapeutic, 23, 266 Medigap policies, 33
Lift, mechanical, 720, 792, 809–811 therapist, 62, 65, 67 Meditation, 22, 97, 266
Light Master’s degree, 40 Meiosis, 144–145
curing, 625, 634, 639 Material Safety Data Sheets (MSDSs), Melanoma, 154–155
dental, 575, 580, 592–594 336–339 Memorandums, telephone, 979
Limb restraints, 901–904 Math Meniere’s disease, 181
Linen conversion chart, 853, 1027–1028 Meninges, 171
bed, 812–813 English/household measurements, Meningitis, 175
infection control, 365, 368, 812–813 775–776, 1027–1028 Mental health
isolation, 408 metric measurements, 720, 774–775, careers, 52–54
wrapping autoclave, 371–372, 373–376 853, 1027–1028 development, 236–247
Lines of authority, 35–37 Roman numerals, 773–774 facilities, 30
Lipids temperature conversion, 413–414, 415, services, 30, 52
digestion, 205–206, 301 1027 technician, 52–53
function, 297–298 Matriarchal, 262 wellness, 19
Liquid Maxillary Mercury
diet, 310 bone, 158, 160, 558 dental, 632–633, 636–637
measurements, 774–776, 849–854, infiltration, 618 disposal, 416–417, 632–633, 636–637
1027–1028 teeth, 558–560 poisoning, 416–417, 441, 632–633
Listening, 88 Mechanical lift, 720, 792, 808–811 Messages
Lithotomy position, 727–728, 730–731 Median plane, 148, 149 communication, 86–88
Liver, 205, 207–208, 301, 323 telephone, 979
Index 1069
Metabolism, 301–302 Myocardial infarction, 193, 513, 517 practical, 55–57, 781
Metric Myopia, 178, 179, 734 practitioner, 56
conversion chart, 720, 853, 1028 Myths, aging, 276–278 registered, 55–57, 92, 781
measurements, 720, 853, 1027–1028 Myxedema, 220 skills, 779–929
Microbiology, 77, 351–355 vocational, 55–57, 781
Microchips, 526
Microencephaly, 717 N Nursing homes, 28–29, 285–286
Nutrients, 297–301
Microhematocrit, 671–676 Nails Nutrition
Microorganism, 7, 8, 351–355, 357–359 anatomy, 152 careers, 57–58
Microscope, 650–655 care, 825, 834–835 diet, 82, 266, 295–313
Middle adulthood, 238, 245 health worker, 84, 360 feeding patient, 855–858
Midsagittal plane, 148, 149, 558 Name badge, 83–84 Nutritionist, 57–58
Midstream urine specimen, 877–878, Nasal cavity, 149, 150
882–884
Midwife, nurse, 56
Nasogastric tube, 849–850
National Center for Complementary and
O
Military time, 1029 Alternative Medicine (NCCAM), 20 Obesity, 100, 307–309
Minerals, 297, 298, 300 National Center for Health Statistics, 717, OBRA, 18, 56–57, 900
Mitered corner, 812, 813–815 718 Observations, 91–92, 737, 826, 909
Mitosis, 144 National health care plan, 23 Obstetrician, 51
Mitten National Health Care Skill Standards Obstructed airway, 457, 469–473, 856
restraint, 901 (NHCSS), 43, 44–45, 1026 Obstructive pulmonary disease, 201
transfer technique, 385–386, 388 National Institutes of Health (NIH), 20, Obtaining direct smear, 656–660
Models, dental, 598–601, 608–614 31, 325 Occult blood, stool, 879–880, 887–888
Modified-block letters, 994–999 Naturopaths, 20 Occupational Exposure to Hazardous
Moist compress, 954–955, 963–964 Needles Chemicals Standard, 336–338
Monkeypox, 354 dental anesthesia, 618–624 Occupational health clinics, 31
Montgomery straps, 909–910 disposal, 365, 367, 370, 620–621 Occupational Safety and Health Adminis-
Morgue kit, 925 Needlestick Safety and Prevention Act, tration (OSHA), 32, 336–338, 363–364,
Mortuary 363–364 416, 441
assistant, 54–55 Needs Occupational therapist, 61–62, 64, 67
careers, 54–55 elderly, 16, 238, 247, 291–292 Occupied bed, 812, 817–820
Mounting human, 240, 241, 242, 247, 250–255 Odontology, 554
electrocardiogram, 762, 767–768 Negligence, 105 Office
radiographs (X-rays), 639–641, 644–645 Nephritis, 214 business and accounting skills,
Mouth Nephron, 211–212, 214, 283 969–1020
anatomy, 204–205, 206, 301 Nerve tissue, 145, 146, 169 dental, 29, 574
care, 824, 827–832 Nervous system, 95, 146, 147, 168–176, medical, 29, 35–36
cavity, 149, 150 281–282 Oil retention enema, 889, 896–898
Mouthpieces, 365, 368, 370, 453 Net income, 543–545 Older Americans Act, 292
Moving patient Networks, 325–326 Olfactory receptors, 181, 182
bed, 790–802 Neuralgia, 175 Ombudsman, 292
chair, 790–793, 803–806 Neurologist, 51 Omnibus Budget Reconciliation Act
emergency care, 450, 451–452, 454 Neuron, 146, 169 (OBRA), 18, 56–57, 900
mechanical lift, 720, 792, 809–811 Nightingale, Florence, 9, 10 Oncologist, 51
stretcher, 790–793, 806–808 NIH, 20, 31, 325 Open
wheelchair, 720, 790–793, 803–806 Nocturia, 213, 283 bed, 812, 820–821
MRI, 71, 323 Nonpathogen, 351 wound, 473–479
Multicompetent or multiskilled worker, 42 Nonprofit agencies, 32 Operating room technician, 63, 66, 67, 92
Multiple sclerosis, 175 Nonretention enemas, 889–894 Operative care, 750–751, 906–916
Muscle Nonverbal communication, 88, 262–263 Ophthalmic
aging changes, 279–280 Normal saline enema, 889–894 assistant, 60–61
anatomy, 145, 146–147, 163–168 Nose laboratory technician, 60–61
contracture, 165, 790–791, 932 anatomy, 181, 182, 197–198 medical technologist, 60–61
kinds, 146–147, 164 cavity, 149, 150, 197–198 technician, 60–61
movements, 164–165, 166, 933 examination, 737, 741–742 Ophthalmologist, 60–61
range of motion, 166, 932–940 injuries, 201–202, 507, 511 Ophthalmoscope, 734, 738–739
skeletal, 163–168 Nosebleed, 201–202, 507, 511 Opportunistic infection, 231, 355
spasms, 168 Nosocomial infection, 355 Optical centers, 29–30, 60–61
strain, 168 Note, explanation of, xxxi, 551 Optician, 60–61
tissue, 145, 146–147 Nuclear medicine technologist, 71 Optometrist, 60–61
tone, 165 Numerical filing, 970–971, 974–977 Oral
using correctly, 334–336 Nurse cavity, 149, 150, 204–205, 206
Muscular anesthetist, 56 evacuator, 576–578, 581, 582
dystrophy, 167 assistant, 55–57, 779–929 intake, 849–854, 855–858
system, 146, 147, 163–168, 279–280 careers, 55–57 hygiene, 594–598, 824, 827–832
Music therapist, 63, 66, 67 clinical specialist, 56 medication, 770–771
My Pyramid, 302–305 educator, 56 surgery, 46, 584, 587–589
Myasthenia gravis, 167–168 midwife, 56 temperature, 415, 421–422
1070 INDEX
Orbital cavity, 149, 150 Pelvic Plaster models, 598, 601, 608–611
Orchitis, 226 cavity, 149, 150 Platelets, 190–191, 682–683
Organ girdle, 159 Play therapy, 22
anatomy, 147, 151–234 inflammatory disease (PID), 230 Pleurisy, 202
donation, 268–271 Penis, 225–226, 284 Pneumonia, 202
Organisms Peptic ulcer, 210 Podiatric medicine, 50
classes of, 351–355 Perfusionist, 63, 66, 67 Poisoning, first aid, 483–488
human, 141–234 Periapical radiographs (X-rays), 640 Polycarboxylate, 601, 629–630
Organizational structure, 35–37 Perineal care, 845–846, 867–870 Polycythemia, 673, 677, 692
Organizations, student, 1022–1025 Perineum, 228, 229 Polysiloxane, 600–601
Orthodontics, 46 Periodontics, 46 Polysulfide, 599–600, 605–608
Orthopedist, 51 Periodontium, 556, 557, 585 Polyvinylsiloxane, 600–601
Orthopnea, 434 Peripheral nervous system, 169–170, Portfolio, career, 535–536
OSHA, 32, 336–338, 363–364, 416, 441 172–173 Positioning patient
Osteomyelitis, 162 Peritonitis, 210 bed, 790–802
Osteopathic medicine, 50 Permanent teeth, 554–557, 559–560 dental chair, 575–576, 580–581, 592–594
Osteoporosis, 162, 279, 296, 719 Pernicious anemia, 191 examinations, 725–732
Ostomy care, 872–876 Personal shock, 480–481, 482, 728
Otitis, 181 appearance, 82–84 Positive thought, 22
Otosclerosis, 181 characteristics, 85–86, 529–530 Positron emission tomography (PET),
Otoscope, 738–740 hygiene, 84, 823–849 71–72, 323
Outpatient services, 16, 29 protective equipment, 338, 363, 365, Postmortem care, 925–927
Output records, 849–854 366–367, 369–370, 398, 574 Postoperative, 908–910, 913–915
Ovarian cancer, 229–230 qualities, 81–102, 529–530 Post-secondary education, 40–42
Ovaries, 217, 218, 223, 227, 228 safety, 251, 341–342 Posture, 82, 334–336
Overweight, 307–309, 717 space, 263–264 Power of Attorney (POA), 113, 114
Oximeter, pulse, 322, 922 PET, 71–72, 323 PPOs, 33, 34
Oxygen, 199–200, 281, 919–924 Pet therapy, 22 Practical nurse, 55–57
pH of urine, 700, 702 Precautions, standard. See standard pre-
P Pharmacist, 62, 64, 67, 320
Pharmacy technician, 62, 64
cautions
Preferred Provider Organizations (PPOs),
Pacemaker, cardiac, 187 Pharynx, 198, 205 33, 34
Paging systems, 981 Phenylalanine, 702–703 Prefixes, 127–139
Pain, 181, 265–266, 413, 909 Phlebitis, 193 Prejudice, 89–90, 260–261
Pajamas, changing, 825–826, 840–842 Phlebotomist, 69, 70 Premenstrual syndrome (PMS), 230
Palliative care, 248–250 Photometer, 677, 680–682 Preoperative, 906–907, 910–913
Pancreas, 207, 208, 217, 218, 221–223, 301 Physiatrist, 51, 61, 64 Presbyopia, 178, 179
Pancreatitis, 209–210 Physical Pressure
Pandemic, 23–24, 397 abuse, 105, 292 bandage, 475, 477–478
Panoramic X-ray, 640 changes of aging, 245–246, 278–284 points, 475, 478
Papanicolaou (Pap) test, 737, 743–745 development, 236–247 sense, 181
Paralysis, 175 disabilities, 89, 286–287 ulcer, 790–791
Paramedic, 48–49 examination, 737–747 Preventive services, 16
Paraplegia, 175, 325 needs, 250–251 Primary teeth, 554–557, 558–560
Parasympathetic nervous system, 95, 173 records, 972–973, 987–993 Privacy
Parathyroid gland, 217, 218, 220–221 restraints, 105, 900–906 invasion of, 105
Parenteral medications, 771, 772 therapist, 62, 64, 67 providing, 284, 321, 340, 725, 826, 859,
Parkinson’s disease, 175, 526 therapy, 62, 64, 67, 930–968 989
Partial bed bath, 823 wellness, 18 rule, 108–110, 321, 329–331
Passport, career, 535–536 Physician Privileged communications, 107, 108, 110
Pasteur, Louis, 9, 10 assistant, 50–51 Problem-solving method, 96
Pathogens, 351–359 careers, 50–52, 320, 716–717 Procedure section, xxxi, 551
Pathologist, 51 offices, 29 Process technician, 77, 78–79
Pathologist, speech-language, 63, 66, 67 specialties, 51 Proctologic position, 728–729, 731–732
Pathology assistant, 51 Physician’s Current Procedural Terminol- Professional
Pathophysiology, See Diseases ogy, 1000–1003 appearance, 82–84
Patience, 85 Physician’s Desk Reference (PDR), 768–770 education, 41–42
Patient care technician, 56, 92, 781 Physiological needs, 250–251 ethics, 111–112
Patient controlled analgesics (PCAs), 909 Physiology, 77, 140–234 leadership, 94–95
Patient Self-Determination Act (PSDA), Phytochemicals, 22 negligence, 105
113–115 Pick-up transfer technique, 385–386, 388 standards, 115–116
Patient’s Pigmentation, skin, 153–154 Projection, 254
rights, 112–113 Pineal body, 217, 223 Prone position, 726, 729
safety, 339–342 Pituitary gland, 216–219 Prostate gland, 225, 283
Patriarchal, 262 Placenta, 223 Prostatic
PDR, 768–770 Plague, 5, 6, 357, 358 cancer, 226
Pediatrician, 51 Planes, body, 148–149, 558 hypertrophy, 226, 283
Pedodontics, 46, 640 Plaque, 594 Prosthodontics, 46
Pegboard system, 1007–1012 Plasma, 187–188, 190
Index 1071
Protective glucose, 695–699 composite, 572, 584, 587, 589, 634,

equipment, personal, 338, 363, 365, urine, 701–705 637–639
366–367, 369–370, 398, 574 Reality orientation, 290–291 instruments, 584–591
isolation, 402 Recap device, 620–621 Restraints, 105, 900–906
Proteins Receipts, 1007–1008, 1013–1014, Resume, 530–537
diet, 311 1018–1019 Resuscitation devices, 365, 368, 370, 453
digestion, 203–208, 301 Records Retention enemas, 889, 896–898
function, 297, 298 admission, 72–74, 782–784 Retinitis pigmentosa, 1020
urine, 213, 700, 702–703 dental, 568–573 Retirement, 246, 285
Protoplasm, 142 computer, 107–110, 319, 972–973, 985, Reverse isolation, 402
Protozoa, 352–353 1004, 1009–1010 Rh factor, 688, 690–691
Psoriasis, 155, 156 filing, 970–977 Rhinitis, 202
Psychiatric technician, 52–54 financial, 1007–1012 Ribs, 158–159
Psychiatrist, 51, 52–54 insurance, 32–35, 999–1006, 1008–1009 Rickettsiae, 353
Psychiatry careers, 52–54 intake and output, 849–854 Right to die, 249–250
Psychological medical, 72–75, 91–92, 107–108, Rights, patient’s, 112–113
abuse, 106, 292 972–973, 987–993 Ringworm, 156, 353
barriers to communication, 89–90 TPR graphics, 435–437 Robots, 79
Psychologist, 52–54 Recreational therapist, 62, 65, 67 Rocky mountain spotted fever, 484
Psychosocial Rectal Roman numerals, 773–774
changes, 246, 284–287 enemas, 889–898 ROMs, 280, 932–940
development, 236–247 examination, 738, 747 Rubber base impression, 599–600, 605–608
Puberty, 242 medication, 771, 890 Ruptured disk, 163
Pubic lice, 232 temperature, 415, 423–424
Pulmonary disease, 201
Pulse
tube, 889, 898–900
Rectum, 205, 207 S
apical, 414, 438–440 Red blood cells. See erythrocytes Safety, 333–349
deficit, 438–439 References, 1052–1059 environment, 338–343
graphing, 435–437 Reflex actions, 238–239, 738–739 equipment, 116, 338–339
oximeter, 322, 922 Reflexology, 22 ergonomics, 338–342
pressure, 440–441 Refractometer, 706, 707–708 fire, 343–347
pressure points, 475, 478 Regions, abdominal, 149, 150 material data sheets, 336–339
radial, 431–433 Registered nurse, 55–57 medications, 772–773
rates, 432 Registration, 41 needs, 251
sites, 431 Regular diet, 302–305, 310 oxygen, 345, 922, 924
Puncture Rehabilitation patient, 116, 339–341
skin, 668–671 careers, 61–67 personal, 251, 334–336, 341
wound, 474 facilities, 28, 29, 31 precautions, 116, 333–349
Pyelonephritis, 214 Reiki, 21 solutions, 338–339
Pyramid, food, 302–305 Religion, 267–272, 291–292, 305, 306 Salary, 543–545
Pyrexia, 416 Renal Saliva
calculus, 215 ejector, 577, 582
Q failure, 215
Reporting
functions, 205, 301
Salivary gland, 205, 301
Quadrants errors, 92, 107 Sanitary manager, 75, 76
abdominal, 149–150 injuries, 341, 364, 368 SARS, 23–24
mouth, 558 observations, 91–92 Satellite clinics/centers, 29
Quadriplegia, 175, 325 Repression, 254 SCANS skills, 536
Quick stain, 683, 686 Reproductive system, 146, 147, 224–233, Scheduling appointments, 319, 978,
284 983–986
R Research
biotechnology, 43, 44–45
SCHIP, 33–34
School health services, 31
Race, 259 computer, 315, 325 Scientist, biological, 77–78, 79
Radial pulse, 431–433 Resident’s Bill of Rights, 112–113 Scoliosis, 163
Radiation therapist, 71 Resistant, antibiotic, 656–657 Search engines, 326–329
Radiographer, 71 Respiration Sebaceous gland, 152, 154
Radiographs, 321–324, 568, 639–645 counting, 414, 433–435 Secondary
Radiologist, 51, 70 process, 199, 433 education, 40
Radiology stages, 199–200, 433 teeth, 554–557
careers, 69, 70–72 Respiratory Secretary
dental, 568, 639–645 infection, 203 skills, 969–1020
Rales, 434 shock, 480 unit, 73, 74
Range of motion (ROM) exercises, 280, system, 146, 147, 197–203, 280–281 Sedimentation
932–940 therapist, 62, 65, 67 erythrocyte, 691–695
Rationalization, 254 therapy technician, 62, 65–66 urine, 701, 709–712
Reagent strips Responder, first, 48–49 Sediments, urinary, 701, 709–710
automated strip reader, 696–697 Restorative materials Seizure, 174, 514, 518
blood, 696–697 amalgam, 572, 584, 587, 589, 632–637 Self-actualization, 253
1072 INDEX
Self-motivation, 85 services, 52 suture removal, 750, 751, 755–756

Senses, special, 91, 146, 147, 176–182, 250, wellness, 19 tray set-up, 385–386, 389–392
281–282 worker, 52–54 Sterile urine specimen, 878
Sensitivity Sociologist, 52–54 Sterilization
personal, 260 Sodium-restricted diet, 311 autoclave, 356–357, 371–378
study, 656–657 Soft diet, 310 dry heat, 357
Septic shock, 480 Solutions wrapping for, 371–376
Severe acute respiratory syndrome (SARS), chemical, 336–338 Sternum, 159, 160
23–24, 353–354 safety, 336–339, 365, 367, 370 Stethoscope, 438, 443, 738–739
Sexual abuse, 106, 292 ultrasonic, 381–384 Stoma, 872–876
Sexuality, 251–252, 284 Somatic nervous system, 170, 172–173 Stomach, 205, 206, 301
Sexually transmitted diseases, 230–233 Sonographer, 69, 71 Stone models, 598, 601, 612
Sharps, disposal of, 365, 367, 370, 620–621 Space, personal, 263–264 Stool specimen, 879–880, 886–888
Shaving Spasm, muscle, 168 Strabismus, 179
operative, 750, 753, 907, 910–911 Specific gravity, urine, 700, 705–709 Straight binder, 917–919
patient, 825, 838–839 Specimens Strains, 168, 499
Shiatsu, 21 culture, 656–667 Stress
Shingles, 175–176 stool, 879–880, 886–888 management, 95–97
Shock urine, 699–701, 853, 877–885 test, 322
first aid, 479–482 Speculum, 738–739 Stretcher, 790–793, 806–808
insulin, 515–516, 518–519 Speech impairment, 89 Stroke
types, 480 Speech-language pathologist, 63, 66, 67 cerebrovascular, 174, 513–514, 517
Shoes, 84 Sphygmomanometer, 441–443, 738–739 heat, 494, 495
Shower, 823, 847–849 Spinal Subject filing, 971
Sickle cell anemia, 191, 683, 692 anesthesia, 908 Sublingual medication, 771
Sigmoid colon, 205, 207 cavity, 149, 150 Succedaneous teeth, 554–557, 559–560
Sigmoidoscope, 726, 738 column, 158, 159 Sudoriferous gland, 152, 153
Sign language interpreter, 74, 75 cord, 158, 171, 173, 325 Suffixes, 127–138
Silicones, 600–601 curvatures, 163 Sugar
Sim’s position, 726, 729–730 injuries, 480, 502 blood, 695–699
Sinuses, 158, 198 Spiritual nutrient, 297
Sinusitis, 202 therapies, 22, 266 urine, 695, 700, 702–703
Sitz bath, 955, 965–966 wellness, 19 Suicide, 243–244
Skeletal system, 146, 147, 156–163, Spirituality, 267–272 Supine position, 726, 729
279–280 Spleen, 196, 323 Support services, 43, 44–45, 75–77
Skill Standards, National Health Care, 43, Splenomegaly, 196 Suppository, 890
44–45, 1026 Splints, 499–501, 503 Suppression, 254
Skilled care facilities, 28–29 Sports medicine, 51, 63, 66, 67 Surfaces, teeth, 565–567, 594–595
SkillsUSA, 1023–1025 Sprains, 161–162, 499 Surgeon, 51, 92
Skin Spreadsheets, 319, 320 Surgery
aging, 279 Standard precautions, 363–371, 397–398, careers, 61, 63, 66, 67
anatomy, 151–156 399, 401, 574–575, 579, 601, 657–658, dental, 46, 584, 587–589
burns, 488–493 669, 701, 740, 751, 812–813, 826, 853, heart, 66, 192
chemical injuries, 483–484, 486–487, 859–860, 867–868, 874, 880, 890, 956 minor, 748–754
490, 492 Standards oral, 46
layers, 151, 152, 489 Bloodborne Pathogen, 338, 363 robotic, 79
preparation, surgery, 750, 753, 907, National Health Care Skill, 43, 44–45, Surgical
910–911 1026 care, 750–751, 906–916
puncture, 668–671 Occupational Exposure to Hazardous clinics/centers, 29
Slander, 106 Chemicals, 336–338 extraction tray, 584, 587–589
Sleep apnea, 202–203 Privacy of Individually Identifiable hose, 909, 915–916
Slides Health Information, 108–110 instruments, 587–589, 748–751
blood, 682–687 professional, 115–116 technologist/technician, 63, 66, 67, 92
culture, 656–657, 660–667 safety, 333–349 Surrogate, health care, 113–115
hemoccult, 879–880, 887–888 State abbreviations, 997 Suture removal, 750, 751, 755–756
urine, 709–712 State Children’s Health Insurance Pro- Swedish massage, 23
Slings, 501, 504 gram, 33–34 Symbols
Smallpox, 357, 358 Statement-receipt, 1007–1008 dental, 570–572
Smear Statistical data sheet, 987, 988, 991–992 icons, xxxi, 551
blood, 682–687 Stem cell, 117, 145, 646 medical, 127
culture, 656, 660–661 Stent, coronary, 192 religious, 268–271, 291–292
direct, 656, 660–661 Stereotype, 260–261 Sympathetic nervous system, 95, 173
Smell, 181, 182, 282 Sterile supply technician, 75, 76, 93 Syphilis, 232–233
Snakebite, 484, 487, 776 Sterile techniques Syringes
Snellen chart, 732–735 dressing change, 395–397 air-water, 577, 581–582
Soap solution enema, 889–894 dressing tray, 389–392 aspirating, 618–624
Social gloves, 392–394 tri-flow, 577, 581–582
changes in aging, 277, 285 minor surgery, 748–754 Systems
development, 236–247 opening supplies, 385–389 body, 146, 147, 151–234
Index 1073
bookkeeping, 1007–1012 Federation Dentaire International (FDI) Therapy

health care, 26–31 System, 561–562, 564 complementary/alternative (CAM),
Systole, 185 flossing, 594–595, 597–598, 824, 827–828 19–23, 264–266
Systolic pressure, 440, 441 function, 204, 301 massage, 23, 65
identification, 558–560 pet, 22
T impressions, 598–608
models, 598–601, 608–614
physical, 930–968
play, 22
Tachycardia, 432 oral hygiene, 594–598, 824, 827–832 spiritual, 19, 22, 267–272
Tachypnea, 434 permanent, 554–557, 559–560 Thermometer
Tact, 85 primary, 554–557, 558–560 cleaning, 419–421
T’ai Chi, 22, 266 radiographs, 568, 639–645 clinical, 415, 416–417
Tap-water enema, 889–894 restoratives, 570, 572, 584, 587, 589, disposable, 418
Tape application, 396, 397 632–639 electronic, 417, 428–429
Taste, 181, 182, 282 secondary, 554–557, 559–560 mercury disposal, 416–417
Tattoos, 84 succedaneous, 554–557, 559–560 reading, 418–419
Taxes, 543–545 surfaces, 565–567, 594–595 temporal, 415–416, 417–418, 430–431
Teamwork, 92–94, 529–530 tissues, 554–557 tympanic, 415, 417, 426–427
Technician types, 558–560 types, 415, 416–418
animal health, 58–60 Universal/National Numbering System, Thermotherapy, 955–956, 959–966
biomedical equipment, 75, 76, 77 560–561, 563, 568–570 Thoracic
biotechnological, 77, 78, 79 X-rays, 568, 639–645 cavity, 149, 150
central/sterile supply, 75, 76 Telemedicine, 18, 326 duct, 195–196
dental laboratory, 46–48 Telepharmacies, 326 Thought, positive, 22
diagnostic vascular, 68, 69 Telephone, 977–983 Thrombocyte, 190–191, 682–683
dialysis, 63, 66 Temperature Thrombolytic drugs, 193
dietetic, 57–58 aural, 415, 417, 426–427 Thrombophlebitis, 193
education, 41–42 axillary, 415, 424–425 Thrombus, 193, 280
electrocardiograph, 68–69 charting, 418–419, 435–437 Thymus, 196, 217, 218, 223
emergency medical, 48–49 converting, 413–414, 415, 1027–1028 Thyroid gland, 217, 218, 220
forensic science, 77, 79 graphing, 435–437 Tick, 484, 487
health information, 73–74, 75, 319–320 groin, 415 Time
medical laboratory, 69, 70, 72, 320, oral, 415, 421–422 management, 97–100
648–714 recording, 418–419, 435–437 military, 1029
medical records, 73–74, 75 rectal, 415, 423–424 Tineas, 156
mental health, 52–54 regulation, 153, 413, 414 Tissues
nurse, 56, 781 temporal, 415–416, 417–418, 430–431 body, 145–147
ophthalmic, 60–61 thermometers, 415, 416–418 lymph, 194–196
ophthalmic laboratory, 60–61 tympanic, 415, 417, 426–427 teeth, 554–557
patient care, 56, 92, 781 variations, 414–416 Tobacco abuse, 82–83
pharmacy, 62, 64 Tendon, 146, 164–165 Today’s research, tomorrow’s health care,
process, 78–79 Tent, oxygen, 920 24, 36, 79, 100, 117, 139, 232, 255, 273,
psychiatric, 52–54 Terminal illness, 90–91, 247 293, 312, 330, 348, 410, 446, 526, 548,
respiratory therapy, 62, 65–66 Terminology 713, 776, 928, 967, 1020
sterile supply, 75, 76, 93 medical, 87, 119–139 Tongue, 181, 182, 204–205, 301
surgical, 63, 66, 67, 92 Physician’s Current Procedural, Tonometer, 734
veterinary, 58–60 1000–1003 Tonsillitis, 196
Technologist Testes, 217, 218, 223, 224, 225, 284 Tonsils, 195–196
animal health, 58–60 Testicular Tooth, See teeth
cardiovascular, 68, 69, 72 cancer, 226 Toothbrushes, 595
clinical laboratory, 68, 70, 72, 648–714 self-examination, 226 Toothpastes, 595
education, 41–42 Tests, waived, 649–650 Topical anesthetic, 618, 750, 771
electroencephalographic, 68, 69 Tetanus, 473, 476, 478 Tornado safety, 345
electroneurodiagnostic, 68, 69, 72 Therapeutic Torts, 104–106
extracorporeal circulation, 63, 66, 67 careers, 44–45, 46–67 Touch
medical laboratory, 68, 70, 72, 648–714 cluster standards, 43, 44–45, 1026 cultural differences, 91, 263–264
nuclear medicine, 71 diets, 266, 309–312 healing, 21
ophthalmic medical, 60–61 massage, 23, 62, 65, 266 nonverbal communication, 88, 262–263
radiologic, 69, 70–72 services, 43, 44–45, 46–47 sense, 181
surgical, 63, 66, 67 touch, 23, 266 therapeutic, 23, 266
ultrasound, 71 Therapist TPR graphs, 435–437
veterinarian, 58–60 art, music, dance, 63, 66, 67 Trachea, 198, 199
Teeth education, 41–42 Training, health care, 40–42
abbreviations, 566–567 massage, 62, 65, 67 Transcriptionist, medical, 73, 74
anatomy, 204, 554–557 occupational, 61–62, 64, 67 Transdermal medication, 771–772
brushing, 594–596, 824, 827–828 physical, 62, 64, 67, 931 Transfer
conditions, 568–573 radiation, 71 belt, 940–941, 945–947
custom tray, 615–617 recreational, 62, 65, 67 forceps, 385–386, 388
deciduous, 554–557, 558–560 respiratory, 62, 65, 67 Transfers
eruption, 554–555 speech-language, 63, 66, 67 chair, 790–793, 803–806
culture specimens, 656–658, 660–665
1074 INDEX
Transfers (continued) Urethra, 212, 213, 225 screening, 732–736

gait belt, 940–941, 945–947 Urethritis, 215–216 services, 29–30, 60–61
mechanical lift, 720, 792, 809–811 Urinal, 859–860, 863–864 Vital signs, 412–447, 908
room/unit, 782–784, 786–788 Urinalysis, 699–701 Vitamins, 297, 298, 299
sterile, 385–392 Urinary Voluntary agency, 32
stretcher, 790–793, 806–808 calculus, 215 Vomiting, inducing, 483, 486
wheelchair, 720, 790–793, 803–806 catheter care, 864–872 Vulva, 228, 229
Transient ischemic attacks (TIAs), 288 conditions, 213–216, 283, 700
Translator, 73, 74, 75
Transmission-based isolation, 397–409
diseases, 213–216, 700
drainage unit, 851, 864–872 W
Transverse plane, 148, 149, 558 reagent strips, 701–705 Walker, 280, 944, 953–954
Trays sediments, 701, 709–712 Ward clerk, 73, 74
custom, 615–617 system, 146, 147, 210–216, 283 Warm water bag, 955, 959–961
dental, 584–591 Urine Warts, 156, 353
dressing, 389–392 components, 213, 700 Washing hands, 359–362, 365, 366
minor surgery, 748–754 production, 211–212 Waste
sterile technique, 385–397 specimens, 699–701, 853, 877–885 disposal, 365, 368, 370
suture removal, 750, 751, 755–756 Urine tests, 699–712 mercury spill, 416–417, 632–633
Trendelenberg position, 728, 731 reagent strips, 699–705 Water, 297, 301
Trends sediment, 701, 709–712 Waterless
health care, 14–25 specific gravity, 700, 705–709 bath, 823–824
historical, 2–14 urinalysis, 699–701 handwashing, 360–361
Triage, 451, 978 Urinometer, 705–707 Watson, James, 11, 12
TRICARE, 34 Urobilinogen, 700, 702–703 Weight
Trichomonas vaginalis, 233, 353 U.S. Department of Agriculture, 302 management, 100, 305–309
Tri-flow syringe, 577, 581–582 U.S. Department of Health and Human measurement, 717–725
Trimming models, 613–614 Services (USDHHS), 31, 108 Wellness, 18–19, 296
Tub bath, 823, 847–849 Uterus, 227–228, 229, 284 West Nile virus, 354
Tub, sitz, 965–966 Wheelchair, 720, 790–793, 803–806
Tube
catheter, 864–872 V Wheezing, 434
White blood cell. See leukocyte
drainage, 851, 864–868, 870–872, 909 Vaccine WHO, 23–24, 31, 1000
feedings, 849–850 anthrax, 358 Will, living, 113, 114
gastrostomy, 849–850 hepatitis, 354, 363 Withdrawal, 255
nasogastric, 849–850 influenza, 202 Word
rectal, 889, 898–900 smallpox, 358 elements, 127–139
Tuberculosis, 203 Valuables, care of, 782, 785, 787, 789, 907, processing, 319
Tularemia, 358 912, 925, 927 Work
Tuning fork, 738–739, 741–742 van Leeuwenhoek, Anton, 7, 8 applying for, 528–549
Turning patient, 454, 792, 797–801 Varicose veins, 193 changes in aging, 277, 285
24 hour Varnish, dental, 625–627 World Health Organization (WHO), 23–24,
clock, 1029 Vascular technologist, 68–69 31, 1000
urine specimen, 878–879, 884–885 Vasectomy, 224 Worms, 354–355
Tympanic Veins Wounds
membrane, 180 anatomy, 187, 189, 190 cleansing, 396, 476, 478
temperature, 415, 417, 426–427 obtaining blood, 324, 668 dressing, 389–392, 473–479, 519–520
Typing blood, 70, 687–691 varicose, 193 first aid, 473–479
Venipuncture, 324, 668 types, 473–474
U Venous blood, 187, 474, 668
Ventral cavity, 149, 150
Wraps
autoclave, 371–376
Ulcer Ventricles bandage, 519–525
digestive, 210 brain, 171, 174–175 Wright’s stain, 683, 685–687
pressure, 790–791 heart, 184–185, 186
Ulcerative colitis, 210
Ultrasonic cleaning, 381–384
Verbal
abuse, 106, 292 X
Ultrasonography, 71, 323–324 communication, 86–88 X-rays
Ultrasound technologist, 71 Verrucae, 156 careers, 69, 70–72
Underweight, 307–309, 717 Vertebrae, 158, 159, 163 dental, 568, 639–645
Uniforms, 83 Veterinarian, 58–60
Uninterrupted power supply (UPS), 329
Unit coordinator, 73, 74
Veterinary careers, 58–60
Villi, 206, 207 Y
Universal/National Numbering System, Viruses, 23–24, 353–354, 358 Yoga, 23, 266
560–561, 563, 568–570 Viruses, computer, 329
Universal precautions. See Standard
precautions
Vision
aging changes, 281 Z
Uremia, 215 careers, 60–61 Zinc oxide eugenol, 625, 630–632
Ureter, 212 defects, 89, 178–179, 281 Zinc phosphate, 625
Ureterostomy, 872
IMPORTANT! READ CAREFULLY: This End User License Agreement (“Agreement”) sets forth the conditions by which Delmar Cengage Learning will make electronic
access to the Delmar Cengage Learning-owned licensed content and associated media, software, documentation, printed materials, and electronic documentation
contained in this package and/or made available to you via this product (the “Licensed Content”), available to you (the “End User”). BY CLICKING THE “I ACCEPT”
BUTTON AND/OR OPENING THIS PACKAGE, YOU ACKNOWLEDGE THAT YOU HAVE READ ALL OF THE TERMS AND CONDITIONS, AND THAT YOU AGREE TO
BE BOUND BY ITS TERMS, CONDITIONS, AND ALL APPLICABLE LAWS AND REGULATIONS GOVERNING THE USE OF THE LICENSED CONTENT.
1.0 SCOPE OF LICENSE
1.1 Licensed Content. The Licensed Content may contain portions of modifiable content (“Modifiable Content”) and content which may not be modified or
otherwise altered by the End User (“Non-Modifiable Content”). For purposes of this Agreement, Modifiable Content and Non-Modifiable Content may be
collectively referred to herein as the “Licensed Content.” All Licensed Content shall be considered Non-Modifiable Content, unless such Licensed Content is
presented to the End User in a modifiable format and it is clearly indicated that modification of the Licensed Content is permitted.
1.2 Subject to the End User’s compliance with the terms and conditions of this Agreement, Delmar Cengage Learning hereby grants the End User, a nontransfer-
able, nonexclusive, limited right to access and view a single copy of the Licensed Content on a single personal computer system for noncommercial, internal,
personal use only. The End User shall not (i) reproduce, copy, modify (except in the case of Modifiable Content), distribute, display, transfer, sublicense, pre-
pare derivative work(s) based on, sell, exchange, barter or transfer, rent, lease, loan, resell, or in any other manner exploit the Licensed Content; (ii) remove,
obscure, or alter any notice of Delmar Cengage Learning’s intellectual property rights present on or in the Licensed Content, including, but not limited to,
copyright, trademark, and/or patent notices; or (iii) disassemble, decompile, translate, reverse engineer, or otherwise reduce the Licensed Content.
2.0 TERMINATION
2.1 Delmar Cengage Learning may at any time (without prejudice to its other rights or remedies) immediately terminate this Agreement and/or suspend access to
some or all of the Licensed Content, in the event that the End User does not comply with any of the terms and conditions of this Agreement. In the event of such
termination by Delmar Cengage Learning, the End User shall immediately return any and all copies of the Licensed Content to Delmar Cengage Learning.
3.0 PROPRIETARY RIGHTS
3.1 The End User acknowledges that Delmar Cengage Learning owns all rights, title and interest, including, but not limited to, all copyright rights therein, in and
to the Licensed Content, and that the End User shall not take any action inconsistent with such ownership. The Licensed Content is protected by U.S., Ca-
nadian and other applicable copyright laws and by international treaties, including the Berne Convention and the Universal Copyright Convention. Nothing
contained in this Agreement shall be construed as granting the End User any ownership rights in or to the Licensed Content.
3.2 Delmar Cengage Learning reserves the right at any time to withdraw from the Licensed Content any item or part of an item for which it no longer retains the
right to publish, or which it has reasonable grounds to believe infringes copyright or is defamatory, unlawful, or otherwise objectionable.
4.0 PROTECTION AND SECURITY
4.1 The End User shall use its best efforts and take all reasonable steps to safeguard its copy of the Licensed Content to ensure that no unauthorized reproduc-
tion, publication, disclosure, modification, or distribution of the Licensed Content, in whole or in part, is made. To the extent that the End User becomes
aware of any such unauthorized use of the Licensed Content, the End User shall immediately notify Delmar Cengage Learning. Notification of such viola-
tions may be made by sending an e-mail to delmarhelp@cengage.com.
5.0 MISUSE OF THE LICENSED PRODUCT
5.1 In the event that the End User uses the Licensed Content in violation of this Agreement, Delmar Cengage Learning shall have the option of electing liquidated
damages, which shall include all profits generated by the End User’s use of the Licensed Content plus interest computed at the maximum rate permitted by
law and all legal fees and other expenses incurred by Delmar Cengage Learning in enforcing its rights, plus penalties.
6.0 FEDERAL GOVERNMENT CLIENTS
6.1 Except as expressly authorized by Delmar Cengage Learning, Federal Government clients obtain only the rights specified in this Agreement and no other
rights. The Government acknowledges that (i) all software and related documentation incorporated in the Licensed Content is existing commercial com-
puter software within the meaning of FAR 27.405(b)(2); and (2) all other data, delivered in whatever form, is limited rights data within the meaning of FAR
27.401. The restrictions in this section are acceptable as consistent with the Government’s need for software and other data under this Agreement.
7.0 DISCLAIMER OF WARRANTIES AND LIABILITIES
7.1 Although Delmar Cengage Learning believes the Licensed Content to be reliable, Delmar Cengage Learning does not guarantee or warrant (i) any informa-
tion or materials contained in or produced by the Licensed Content, (ii) the accuracy, completeness or reliability of the Licensed Content, or (iii) that the
Licensed Content is free from errors or other material defects. THE LICENSED PRODUCT IS PROVIDED “AS IS,” WITHOUT ANY WARRANTY OF ANY KIND
AND DELMAR CENGAGE LEARNING DISCLAIMS ANY AND ALL WARRANTIES, EXPRESSED OR IMPLIED, INCLUDING, WITHOUT LIMITATION, WAR-
RANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. IN NO EVENT SHALL DELMAR CENGAGE LEARNING BE LIABLE FOR:
INDIRECT, SPECIAL, PUNITIVE OR CONSEQUENTIAL DAMAGES INCLUDING FOR LOST PROFITS, LOST DATA, OR OTHERWISE. IN NO EVENT SHALL
DELMAR CENGAGE LEARNING’S AGGREGATE LIABILITY HEREUNDER, WHETHER ARISING IN CONTRACT, TORT, STRICT LIABILITY OR OTHERWISE,
EXCEED THE AMOUNT OF FEES PAID BY THE END USER HEREUNDER FOR THE LICENSE OF THE LICENSED CONTENT.
8.0 GENERAL
8.1 Entire Agreement. This Agreement shall constitute the entire Agreement between the Parties and supercedes all prior Agreements and understandings oral
or written relating to the subject matter hereof.
8.2 Enhancements/Modifications of Licensed Content. From time to time, and in Delmar Cengage Learning’s sole discretion, Delmar Cengage Learning may
advise the End User of updates, upgrades, enhancements and/or improvements to the Licensed Content, and may permit the End User to access and use,
subject to the terms and conditions of this Agreement, such modifications, upon payment of prices as may be established by Delmar Cengage Learning.
8.3 No Export. The End User shall use the Licensed Content solely in the United States and shall not transfer or export, directly or indirectly, the Licensed Content
outside the United States.
8.4 Severability. If any provision of this Agreement is invalid, illegal, or unenforceable under any applicable statute or rule of law, the provision shall be deemed
omitted to the extent that it is invalid, illegal, or unenforceable. In such a case, the remainder of the Agreement shall be construed in a manner as to give
greatest effect to the original intention of the parties hereto.
8.5 Waiver. The waiver of any right or failure of either party to exercise in any respect any right provided in this Agreement in any instance shall not be deemed
to be a waiver of such right in the future or a waiver of any other right under this Agreement.
8.6 Choice of Law/Venue. This Agreement shall be interpreted, construed, and governed by and in accordance with the laws of the State of New York, applicable
to contracts executed and to be wholly preformed therein, without regard to its principles governing conflicts of law. Each party agrees that any proceeding
arising out of or relating to this Agreement or the breach or threatened breach of this Agreement may be commenced and prosecuted in a court in the State
and County of New York. Each party consents and submits to the nonexclusive personal jurisdiction of any court in the State and County of New York in
respect of any such proceeding.
8.7 Acknowledgment. By opening this package and/or by accessing the Licensed Content on this Web site, THE END USER ACKNOWLEDGES THAT IT HAS READ
THIS AGREEMENT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS. IF YOU DO NOT ACCEPT THESE TERMS AND CON-
DITIONS, YOU MUST NOT ACCESS THE LICENSED CONTENT AND RETURN THE LICENSED PRODUCT TO DELMAR CENGAGE LEARNING (WITHIN 30
CALENDAR DAYS OF THE END USER’S PURCHASE) WITH PROOF OF PAYMENT ACCEPTABLE TO DELMAR CENGAGE LEARNING, FOR A CREDIT OR A RE-
FUND. Should the End User have any questions/comments regarding this Agreement, please contact Delmar Cengage Learning at delmarhelp@cengage.com.
Delmar Cengage Learning End User License Agreement, December 2007

Diversified Health Occupations (Red Textbook) 7th Editions

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Diversified Health Occupations (Red Textbook) 7th Editions

Uploaded by

Copyright:

Available Formats

DIVERSIFIED

Louise Simmers, MEd, RN

Vice President, Marketing, Career and

Delmar Cengage Learning

Cengage Learning products are represented in Canada by Nelson Education, Ltd.

For your lifelong learning solutions, visit delmar.cengage.com

Visit our corporate website at www.cengage.com

Notice to the Reader

CHAPTER 2 Health Care Systems 26

CHAPTER 3 Careers in Health Care 38

3:6 Biotechnology Research Summary 80

CHAPTER 4 Personal and Professional Qualities

CHAPTER 5 Legal and Ethical Responsibilities 103

CHAPTER 6 Medical Terminology 119

CHAPTER 7 Anatomy and Physiology 140

CHAPTER 8 Human Growth and Development 235

CHAPTER 9 Cultural Diversity 257

CHAPTER 10 Geriatric Care 275

CHAPTER 11 Nutrition and Diets 295

CHAPTER 12 Computer Technology in Health Care 314

CHAPTER 13 Promotion of Safety 333

CHAPTER 14 Infection Control 350

CHAPTER 15 Vital Signs 412

CHAPTER 16 First Aid 448

16:12 Applying Dressings and Bandages 519 Internet Searches 526

CHAPTER 17 Preparing for the World of Work 528

CHAPTER 19 Laboratory Assistant Skills 648

CHAPTER 20 Medical Assistant Skills 715

CHAPTER 21 Nurse Assistant Skills 779

CHAPTER 22 Physical Therapy Skills 930

CHAPTER 23 Business and Accounting Skills 969

Diversified Health Occupations, seventh edition, was written to pro-

OBRA Requirement—Based on Federal Law ♦ A free StudyWARE™ CD-ROM is packaged

Diversiﬁed Health WebTutor to Accompany

Electronic Classroom Manager ♦ Learning links that offer students a short

Objectives CHAPTER 16 First Aid

Review these goals before you begin reading a

presented to reinforce the meaning of the icons. Legal Responsibility

30216_16_Ch16_448-527.indd 448 1/11/08 1:21:54 PM

TODAY’S RESEARCH: TOMORROW’S HEALTH CARE

Career CAREER HIGHLIGHTS

RELATED HEALTH CAREERS

30216_07_Ch07_140-234.indd 141 1/11/08 1:46:19 PM

Sections To prevent injury to yourself and others while

30216_13_Ch13_333-349.indd 334 1/11/08 1:25:44 PM

30216_15_Ch15_412-447.indd 421 1/11/08 1:26:29 PM

Full-Color Photos and Illustrations

Internet INTERNET SEARCHES

Use the suggested search engines in Chapter 12:4

Searches of this textbook to search the Internet for addi-

Review 2. Microbiology: search for specific information

Questions rickettsiae, and viruses

you find yourself unable to answer the

30216_14_Ch14_350-411.indd 411 1/11/08 1:46:54 PM

This seventh edition of Diversified Health Occupations is dedicated

Eleanore Cross Linda Stanhope

Carson’s Scholar Fund Omron Healthcare

Welcome to the world of health science technology educa-

Safety—Proceed with Caution Science Skill Technology

TABLE 1-1 History of Health Care in Ancient Times

THE DARK AGES AND

TABLE 1-3 History of Health Care in the Renaissance

1350–1650 AD Rebirth of science of medicine

FIGURE 1-2 Anton van Leeuwenhoek